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Supplement to the Dutch Journal of Physiotherapy Volume 114 / Issue 3 / 2004
for physical therapy in patients withParkinson's disease As a result of international collaboration in guideline development, the Royal Dutch Society for Physical Therapy (Koninklijk Nederlands Genootschap voor Fysiotherapie, KNGF) has decided to translate her Clinical Practice Guidelines into English to make the guidelines accessible at an international level. International accessibility of clinical practice guidelines in Physical Therapy makes it possible for physical therapists to use guidelines as a reference for treating their patients. Besides, by this, international collaboration in further development and the updating process of guidelines is made possible.
At a national level, countries could endorse guidelines, and adjust guidelines to their local situation if necessary.
2006 Royal Dutch Society for Physical Therapy (Koninklijk Nederlands Genootschap voor Fysiotherapie, KNGF) All rights reserved. No part of this book may be reproduced, stored in an automatic retrieval system, or published in any form of by any means, electronic, mechanical, photocopying, microfilming, or otherwise, without the written permission by the KNGF.
The KNGF represents 20,000 members. The most important activities of the Society are: representing the members' interests, developing the quality of the area of physiotherapy and fortifying the position of physiotherapists in the Netherlands.
In order to develop the quality of physical therapy, the KNGF has invested in Quality Assurance. One of these programs has led to the development of Clinical Practice Guidelines. KNGF Guidelines for physical therapy in patients with Parkinson's disease Clinical practice guidelines
General focal points for treatment Final evaluation, conclusion and reporting Review of the evidence
Definition of the health problem Formation of the guideline development group Procedure of the guideline development group Validation by intended users Formation of the steering group Structure, products and implementation of the guidelines A.11 Evidence for the conclusions and recommendations Consequences of Parkinson's disease Natural course of the complaints KNGF Guidelines for physical therapy in patients with Parkinson's disease The role of the physical therapist Physical therapy in the early phase Physical therapy in the mid phase Physical therapy in the late phase Analysis to formulate the objectives to be tested Questionnaire Patient Specific Complaints Questionnaire History of Falling (Modified) Falls Efficacy Scale Freezing of Gait questionnaire LASA physical activity questionnaire Parkinson's Activity Scale Timed Up and Go test Ten-meter walk test Location of the treatment Involvement of the caregiver Time of treatment Tempo of exercising Recognizing a response fluctuation Contra-indications Frequency and duration of the treatment KNGF Guidelines for physical therapy in patients with Parkinson's disease Improvement of the performance of transfers Stimulate reaching and grasping Prevention of inactivity and maintenance or improvement of physical capacity Prevention of pressure sores Compliance with therapy in the short term Compliance with therapy in the long term C.10 Final evaluation, conclusion and reporting Legal status of the guidelines Revisions of the guidelines G Acknowledgements Appendices
Overview of abbreviations and concepts used in the guidelines Current information Medication in Parkinson's disease Measering Instruments Cognitive movement strategies KNGF Guidelines for physical therapy in patients with Parkinson's disease KNGF Guidelines for physical therapy in patients with Parkinson's disease Clinical practice guidelines for physical therapy in patients with Parkinson's disease S.H.J. KeusI, H.J.M. HendriksII, B.R. BloemIII, A.B. Bredero-CohenIV, C.J.T. de GoedeV, M. van HaarenVI, M. Jaspers VII, Y.P.T. KamsmaVIII, J. WestraIX, B.Y. de WolffX, M. MunnekeXI tion, attention, personality and fear), patients with PD These evidence-based clinical practice guidelines by can be trained in the same way as their contemporar- the Royal Dutch Society for Physical Therapy (KNGF) ies. General principles of physical training are not embody the diagnostic and therapeutic processes discussed in these guidelines, therefore. The following for patients with Parkinson's disease (PD). In the se- areas are not covered by these guidelines due to their cond part of this document, entitled ‘Review of the specialist nature: for problems with writing we recom- evidence', the choices made in these guidelines are mend that the patient is referred to an occupational underpinned by the evidence available and described therapist; for speech problems the patient should be in detail. Appendix 1 contains an overview of the referred to a speech therapist; for urology problems abbreviations and concepts used in the guidelines. to a physical therapist trained to treat pelvic floor These guidelines are developed in cooperation with the Dutch Institute of Allied Health Care (NPi) and with financial support of the Dutch PD Association. Professional target group
These guidelines are applicable by every physical Definition of Parkinson's disease
therapist, irrespective of the work situation. In order These guidelines are aimed at the treatment of to be able to deliver optimal care to patients with PD, patients with PD, with sufficient mental function we recommend that the physical therapist has spe- to comply with treatment, who have no other cific expertise. Knowledge and skills can be developed prominent health problems (co-morbidity). These through the use of these guidelines and by attending KNGF-guidelines do not automatically apply to other courses which address specific aspects of PD, for exam- parkinsonisms, such as multiple system atrophy ple, pathology, diagnostics and management of PD (MSA) and progressive supra-nuclear palsy (PSP). For (see appendix 2). The guidelines can also be used by the treatment of osteoporosis-related problems, the referring physicians, to indicate the potential applica- guideline development group (see A.4.) refers to the tion of physical therapy in the overall management KNGF-guidelines Osteoporosis. When no severe mental impairments are present (e.g. impairments in cogni- Samyra Keus, physical therapist, human movement scientist, Department of Physical Therapy, Leiden University Medical Center (LUMC), Leiden, the Netherlands. Erik Hendriks, physical therapist, epidemiologist, Department of Research and Development, Dutch Institute of Allied Health Care, Amersfoort, the Netherlands; Department of Epidemiology, Maastricht University, Maastricht, the Netherlands. Bas Bloem, neurologist, Department of Neurology, Radboud University Nijmegen Medical Centre (UMCN), Nijmegen, the Netherlands. Alexandra Bredero-Cohen, exercise therapist-Mensendieck, Dutch Institute of Allied Health Care, Amersfoort, the Netherlands. Cees de Goede, physical therapist, human movement scientist, Department of Physical Therapy, VU University Medical Center (VUMC), Amsterdam, the Netherlands. Marianne van Haaren, physical therapist, Rehabilitation Centre Breda, Breda, the Netherlands. Mariken Jaspers, exercise therapist-Mensendieck, Fysio Ludinge, Zuidlaren, the Netherlands. Yvo Kamsma, physical therapist, human movement scientist, Center for Human Movement Sciences, University of Groningen, the Joke Westra, physical therapist, Nursing home Maartenshof, Groningen, the Netherlands. Beatrice de Wolff, exercise therapist-Cesar, movement scientist, Medical Center De Vecht, Groningen, the Netherlands. Marten Munneke, physical therapist, human movement scientist, epidemiologist, Department of Physical Therapy, Leiden University Medical Center (LUMC), Leiden, the Netherlands; Department of Neurology, Radboud University Nijmegen Medical Centre (UMCN), Nijmegen, the Netherlands. KNGF Guidelines for physical therapy in patients with Parkinson's disease pneumonia or heart failure. Aspiration pneumonia PD is a progressive neurological disorder. Degeneration can be directly caused by primary health problems, of dopamine-producing cells in the substantia such as difficulties with swallowing. The severity of nigra (part of the basal ganglia) leads to a decreased the disease is often classified according to the Hoehn dopamine-production. The cause of the damage and Yahr classification (see table 7). is unknown. Therefore, in the literature, it is also referred to as the idiopathic form of PD.
A clinical diagnosis of ‘PD' is made if a patient shows Patients with PD can be classified as tremor-domi- bradykinesia accompanied by at least one of the fol- nated or akinetic-rigid. An akinetic-rigid type of PD lowing symptoms: presents with the initial symptoms of rigidity and 1. Rigidity of the muscles; hypokinesia. These patients are characterized by 2. Resting tremor (4-6 Hz); problems with maintaining balance and with gait 3. Balance impairments that are not caused by pri- (including freezing), and show a more rapid course mary visual, vestibular, cerebellar or propriocep- of the disease. In the tremor-dominant group, the tive dysfunction. disease tends to develop more slowly, with dementia and cognitive impairments occurring less frequently. Limitations in activities (disabilities) and participa- Prognostic factors that indicate a rapid progression, tion restrictions arise as a consequence of impair- which cannot be influenced, are: 1) diagnosis at an ments in body functions and body structures. For an older age; 2) presence of severe depression; 3) demen- extensive description see table 5 and 6, respectively. tia and 4) comorbid arteriosclerosis. Prognostic fac- tors that can be influenced are: 1) physical inactivity In the Netherlands PD prevalence is approximately Physical inactivity increases the risk of developing 1.4% among people older than 55 years, and increas- complaints including osteoporosis, constipation, and es with age (55-64 years: prevalence 0.3%; > 95 years: cardiovascular and respiratory problems. In combina- prevalence 4.3%). There is no significant difference tion with the increased risk of osteoporosis, falling in prevalence between men and women. Based on can lead to fractures or other physical injury and to demographics, the absolute number of patients (increased) fear to move, resulting in a reduced level with PD in the Netherlands is expected to rise to of activity and a further increased liability to new almost 70,000 by 2015. The incidence of PD in the Netherlands is estimated at 7,900 patients each year. The role of the physical therapist
For patients with PD, the objective of the physical Although PD is progressive, the natural course of therapist is to improve the quality of life by maintain- health problems varies substantially from patient to ing or increasing the patient's independence, safety patient. Usually, it has progressed to a bilateral disor- and well-being. This is achieved through prevention der three years after the first (unilateral) symptoms of inactivity and falls, improving functional activity were observed. Balance problems develop about two and decreasing limitations in activities. Treatment to three years later. On average, recurrent falling starts goals and successive interventions can be determined ten years after the first symptoms. Eventually, almost based on the phases patients go through (quick all patients will have impaired balance and will suffer reference card 3). The physical therapeutic interven- from repeated falls. Because of increasing problems tion goals apply to the phase addressed, but are also with balance, patients may become permanently important in subsequent phases. confined to a wheelchair. In later stages, non-motor symptoms may arise, such as dementia. Furthermore, Early phase
health problems of these patients increase when age- Patients in the early phase have no or little limita- related co-morbidity is present. Patients, whether tions. According to the Hoehn and Yahr classifica- living on their own or in nursing homes, often die of tion, they are classified in the stages 1 to 2.5. The goal KNGF Guidelines for physical therapy in patients with Parkinson's disease of therapeutic intervention in this phase, but as well and shoulder complaints; in the subsequent phases is: • need for information about the consequence of 1. prevention of inactivity; PD, especially regarding the limitations in activities 2. prevention of fear to move or to fall; concerning posture or movement.
3. preserving or improving physical capacity (aerobic capacity, muscle strength, and joint mobility). The strain on the caregiver can also be a reason for referral when the patient's activities are greatly limit- The physical therapist can achieve these goals by giv- ed (e.g. lifting instruction if the patient is confined to ing information and advice, exercise therapy (possi- a wheelchair or bed). Early referral is recommended bly in a group), with specific attention to balance and (immediately after diagnosis) to prevent or decrease physical capacity. complications as a result of falling and inactivity.
Mid phase
In the mid phase, patients develop more severe symp- I Diagnostic
toms; performance of activities become restricted and The diagnostic process consists of taking the medical problems with balance and an increased risk of falls history, an analysis of the medical history, performing arise. Patients are classified in stages 2 to 4, according a physical examination and drawing up a treatment to Hoehn and Yahr. The goal of therapeutic inter- plan. The objective of the diagnostic process is to vention in the mid and late phases is to preserve or assess the severity and nature of the patient's health stimulate activities. Exercise therapy is focused on the problems and to evaluate the extent to which physi- following problem areas: cal therapy can influence these problems. Starting point is the patient's request.
Referral
If a patient is referred by a primary care physician (PCP) or a medical specialist, the physical therapist assesses whether the referral contains sufficient infor- Cognitive movement strategies and cueing strategies mation concerning possible co-morbidity (e.g., oste- can be used and if necessary the caregiver* can be oporosis and other disorders that decrease mobility, involved in the treatment applied.
such as arthritis, rheumatoid arthritis, heart failure and COPD). Furthermore, it is important for the physi- Late phase
cal therapist to know if other forms of parkinsonism In the late phase of the disease, patients are confined were excluded. Information should be received on to a wheelchair or bed. They are classified in stage 5, the course of the health problem, on possible mental according to the Hoehn and Yahr classification. The disorders related to PD, on the treatment policy, and treatment goal in this phase is to preserve vital func- on the result of the medical treatment.
tions and to prevent complications, such as pressure sores and contractures. When taking the patient's history, the physical thera- Indications for physical therapy
pist assesses and records the health problems (see Physical therapy is indicated if there is/are: quick reference card 1). In addition, the patient's • limitations in activities and impairments in func- expectations regarding interventions and treatment tion especially with respect to transfers, body pos- outcome are recorded. The physical therapist tries to ture, reaching and grasping, balance and gait; assess whether the patient's expectations are realistic. • inactivity or a decreased physical capacity; When mental impairments or physical impairments • increased risk of falls or fear to fall; or limitations impede the patient in answering ques- • increased liability to pressure sores; tions, and when the patient is largely dependent on • impairments and limitations as a result of neck others for care, it is necessary to involve the caregiver The term caregiver refers to both the partner and any other person who takes care of the patient. KNGF Guidelines for physical therapy in patients with Parkinson's disease to get an accurate picture of the patient's health pro- receive a falls diary (see appendix 4.3). In addition, several measures for identification can be used: fear to fall is identified with the (modified) Falls Formulating the objectives for physical examina-
Efficacy Scale (see appendix 4.4); balance problems are assessed using the Retropulsion test (impaired The information obtained whilst taking the patient's postural responses to external perturbations) (see history should be used to formulate a number of appendix 4.5); freezing of gait is evaluated with the objectives for physical examination. These objectives Freezing of Gait Questionnaire (see appendix 4.6); are focused on the examination of: physical capacity; in case of doubts with respect to the patient's level transfers; body posture; reaching and grasping; ba- of activities in comparison with the Dutch Standard lance and gait.
of Healthy Moving, the LASA Physical Activity Questionnaire can be used (see appendix 4.7); the I.III Physical
Six-minute walk test should be performed in patients Due to fluctuations in good (on) or bad (off) response who are not troubled by freezing; the Ten-meter walk to the use of levodopa, mobility problems of patients test should be used to evaluate comfortable walking with PD can vary greatly during the day. Therefore, speed (see appendix 4.8 and 4.9, respectively); with during physical examination, the physical therapist the Modified Parkinson's Activity Scale, the quality has to find out if the patient is in an on or off period. of movement during certain ADL can be documented The physical therapist can make use of quick refer- (see appendix 4.10); the Timed Up and Go test is used ence card 2 as a means to perform a structured physi- to determine how quickly certain activities can be cal examination. Whilst taking the medical history performed (see appendix 4.11). the physical therapist determines if the patient has other disorders that need to be included in the physi- cal examination (e.g. neck-shoulder complaints or To conclude the diagnostic process, the physical ther- back complaints that seem to be associated with PD).
apist should answer the following questions: • Is physical therapy indicated for the patient? I.IV Outcome
• Can the guidelines be applied to this individual Outcome measures serve as an aid in charting and objectively assessing problems associated with PD. Furthermore, a number of outcome measures can be Physical therapy is indicated when: used again later to evaluate the effects of treatment. 1. the patient is limited in one or more activities As a result of medication, motor function and activity (transfers, body posture, reaching and grasping, limitation can vary greatly during the day. Therefore balance and gait); it is important that measurements are performed at 2. the patient's physical capacity is getting worse or the same time of the day as the initial measurement, if there is a risk this will happen; assuming that patients always take their medication 3. the patient has as increased risk of falling or has a at the same time. See appendix 3 for an overview of possible medication. 4. there is a need for information or advice on the The Patient Specific Complaints questionnaire, a disorder, natural course and prognosis, especially patient preference outcome scale, is used to evaluate on posture and movement and functioning in the extent to which the patient feels limited in activi- ties, and the most important limitations in activities (see appendix 4.1). In addition, this questionnaire The patient is only eligible for physical therapy if can be used to develop a list of the patient's most there are no medical problems for which therapy important problems. Incidence of falling and pos- would be contraindicated, no personal or social fac- sible risk of falling is determined with the History tors that would prevent compliance with therapy, of Falling Questionnaire (see appendix 4.2). Patients and if the physical therapist determines that the who have fallen more than once in the past year patient's impairments in functions, limitations in KNGF Guidelines for physical therapy in patients with Parkinson's disease activity and the behavioral aspects can be influenced II Therapeutic
by physical therapy. If physical therapy is indicated and the guidelines are General focal points for treatment
applicable, the physical therapist formulates, in con- Involvement of the caregiver
sultation with the patient, a treatment plan in which It is very important to involve the caregiver in treat- individual treatment goals are included. If the physi- ment. The caregiver can assist in using cues and cal therapist does not feel that therapy is appropriate, cognitive movement strategies when the patient has he should inform the referring physician and may problems applying these learned strategies in daily advise referral to another allied health discipline or to life (e.g. in case of a poor mental function). The a medical specialist.
patient will benefit from one instruction at a time, especially if there are mental impairments, such as I.VI Treatment
impairments in memory and attention. It is impor- The treatment plan will primarily focus on the main tant to reduce the strain on the caregiver. This is pos- problem that is in line with the patient's request. sible, for example, by teaching the caregiver lifting In formulating the main goals (intended treatment techniques when the patient with PD is confined to outcome), the patient's motivation, capability and a wheelchair or bed, and by indicating how to act in understanding are taken into account. Physical thera- case of freezing and on/off-periods.
peutic goals for patients with PD are: 1. to stimulate the patient's safety and independence Avoidance of dual tasking
in the performance of activities, with the empha- Most patients with PD are unable to pay full attention to all tasks when performing several tasks simultane- ously (dual or multitasking). In particular, patients with PD need to pay specific attention in order to c. reaching and grasping; safely perform ‘automatic movements' such as walk- ing. Dual tasks can have a negative effect on gait and balance, which can give rise to unsafe situations in 2. to preserve or improve physical capacity; daily life as well as during treatment. Avoiding per- 3. to prevent falling; formance of dual tasks, during treatment as well as 4. to prevent pressure sores; in daily life, increases safety of patients with PD and 5. to stimulate insight into impairments in function can decrease falls. Accordingly, the physical therapist and limitations in activities, especially of posture should not give further instructions during the per- and movement.
formance of an activity or movement as this will lead Besides treatment goals, the treatment plan includes the interventions that will be carried out to achieve these goals, the expected number of sessions, treat- Often, different disciplines are often involved in ment frequency, and treatment location (at home, in treatment of patients with PD (especially those who the clinic, in the hospital or care home). The choice are in the late stages or have a complex presentation). of the location is determined by the treatment goal The moment at which another discipline becomes and will also depend on the patient's and therapist's involved, and by which procedure, depends on the personal capabilities and on external factors. If treat- referring physician and on the way health care is ment is primarily aimed at enhancing functional organized in the region where the physical therapist activity, it will preferably take place at the patient's operates. It is recommended that agreements are home. Enhancing physical capacity can take place in made with the patient, caregiver, and other persons the therapist's clinic. concerned in relation to the organization of care. This will help to fine tune the package of multidisciplinary care received by the patient. KNGF Guidelines for physical therapy in patients with Parkinson's disease • When a patient has a deep brain stimulator The choice of group or individual treatment depends implanted (e.g. STN-stimulation) the use of dia- on the treatment goals, the intended result, the thermia (short wave, microwave) is contra-indi- patient's abilities and external factors (such as the cated at any time and for any part of the body.
availability of exercise groups). If personal goals • Mental impairments, such as impairments in are most prominent, e.g. improvement of transfers, cognition (e.g. poor memory, dementia and individual treatment is most suited. The physical severe hallucinations), personality and atten- therapist can provide specific instruction and atten- tion, are relative contra-indications for treat- tion, with the additional advantage that patients will ment of problems that are associated with be less distracted by their environment than during PD, because these impairments influence the group treatment.
patient's ability to learn. Group treatment is more suited to general goals. • Freezing problems form a relative contra-indica- This may be the case when providing a maintenance tion for hydrotherapy. Hydrotherapy can only program, and when the goals are related more to take place for patients who are affected by freez- physical performance e.g. improving physical capac- ing if they are individually supervised.
ity or increasing well-being by and during activity. • General fatigue can influence both treatment Furthermore, group therapy provides an opportu- plan and schedule (e.g. spreading out exercises nity for patients and their caregivers to learn from during the day). one another, there is contact with fellow-sufferers, the social aspect may increase subjective feelings of well-being, and compliance with therapy might be Frequency and duration of treatment
increased. Depending on patient-specific problems, Duration and frequency of a course of physical ther- the therapist will direct the patient to either a spe- apy depend strongly on the needs and potential of cific exercise group for patients with PD, or to a more the patient, and on the course of the disease. For each general exercise group for the elderly (see appendix patient treatment will focus on the main problem 2). Group size depends on the treatment goal and related to his* need. If the patient has achieved the the level of functioning of participating patients (to a goals specified, or if the physical therapist does not maximum of eight patients). Furthermore, in the case expect any changes as a result of therapy (improve- of group treatment it is important that goals are set ment, maintenance or prevention of worsening) and aimed for individually. treatment should be discontinued. Treatment should also be discontinued if the physical therapist assesses Focal points in the treatment of patients with
the patient is able to achieve the treatment goals on his own (without therapeutic supervision). To • When making appointments the physical thera- improve functional ADL a treatment period of four pist should take into account the patient's good weeks is recommended. During the first sessions it and bad periods during the day (on/off periods). will become clear if the use of cues will be helpful. • The cognitive function and the patient's age To improve physical capacity, a treatment of at least determine the pace and degree of difficulty of eight weeks is recommended. Provided patients are given adequate instructions, they can perform the • The physical therapist can train the patient exercises on their own at home; therefore, a low treat- while to recognizing response fluctuations ment frequency (e.g. once a week to adjust the exer- (wearing off-phenomenon, on/off-problems, dys- cise program) is sufficient. Goals should be evaluated kinesias, freezing), which occur with long-term every four weeks and adjusted, if necessary, through- medication use and as the disease progresses. If out the treatment program; information and advice necessary the patient can discuss with his medi- should be given regularly throughout this process. cal specialist if any adjustments in medication KNGF Guidelines for physical therapy in patients with Parkinson's disease II.II Treatment
strategies
patient's attention and facilitate (automatic) move- Cognitive movement strategies
ment. It is suggested that cues allow a movement to To improve transfers, cognitive movement strategies be directly controlled by the cortex, with little or no are used in which complex (automatic) activities are involvement of basal ganglia. Not all patients benefit divided into separate elements consisting of relatively from using cues. Cues can be generated internally simple movement components, which are performed (bow, stretch, wave) or externally. External stimuli in a sequence. By doing this, the person has to think can be divided into moving stimuli (light of a laser consciously about his movements and is thus helped pen, a moving foot, a falling bunch of keys) and non- to avoid dual tasking during complex (automatic) moving stimuli (sound of a metronome, stripes on ADL. Furthermore, the movement or (part of the) the floor, and the grip of a walking-stick). activity will be practiced and rehearsed in the mind. With regard to therapeutic use of cues, a distinction is It is important that movements are not performed made between rhythmical recurring cues and one-off automatically; performance has to be consciously cues (see table 1). Rhythmical recurring cues are given as a continuous rhythmical stimulus, which can serve as a control mechanism for walking. The distance between (frequency of) rhythmical cues during walk- The performance of automatic and repetitive move- ing will be based on the number of steps needed to ments is disturbed as a result of fundamental prob- perform the Ten-meter walk test at comfortable pace. lems of internal control. So-called cues are used to One-off cues are used to keep balance, for example complete or replace this reduced or even absent inter- when performing transfers and for initiating ADL, or nal control. Cues are stimuli either from the environ- when getting started again after a period of freezing.
ment or generated by the patient; they increase the Table 1. Cues. Rhythmic recurring cues
the patient moves on music of a walkman the patient moves on rhythmical ticking of a metronome the patient or someone else sings or counts the patient follows another person the patient walks over stripes on the floor or over stripes he projects to himself with the patient walks with an inverted walking-stick and has to step over the grip the patient taps his hip or leg initiation of movement, for example, stepping out at the third count initiation of movement, for example, by stepping over some else's foot, an object on the floor or an inverted walking-stick maintenance of posture, for example, by using a mirror or by focusing on an object (clock, painting) in the environment initiation of movement (and continuation of walking), for example, by focusing on the spot the wants to go to, and not on the doorway he has to go through KNGF Guidelines for physical therapy in patients with Parkinson's disease Table 2. Core areas for aids in Parkinson's disease. Problem area
Aids or adjustments
• walking aid (i.e. rollator) Transfers or changing • raised toilet • stand-up chair • aids that facilitate getting in or out of bed (such as high-low bed, elevator to lift a patient, sliding board, handles on the sides of the • walking aid (i.e. rollator) • other aids that improve mobility (such as wheelchair, scoot mobile) Falling and increased falls risk • walking aid (i.e. rollator) • shoes with sufficient support and soles with sufficient grip Treatment strategies per treatment goal
The evaluation process consists of: Quick reference card 4 shows an overview of the • evaluation of changes in movement strategies and treatment strategies that can be chosen for different posture: at the beginning of every treatment ses- treatment goals.
• evaluation of changes in physical capacity: after at Aids
least eight weeks; The use of aids can be advisable for some patients • evaluation of final treatment outcome by means with PD. The physical therapist (together with the of its ‘global perceived effect': at the end of the occupational therapist if necessary) provides the treatment (see appendix 4.12). appropriate aid and relevant training in the use of (walking) aids (see table 2). He also provides informa- tion on who is responsible for the maintenance and Preservation of activities in daily life
repair of the aids.
Learned strategies to stimulate the activities in daily Besides, the physical therapist can refer the patient life are sometimes retained for only a short period to an occupational therapist for advice regarding of time. Introducing permanent cues (to initiate possible adjustments in the home environment. For as well as to continue the movement) in the home patients with recurrent falls, a nurse can give advice environment can aid effective long-term use of the on the purchase of hip protectors. strategies. It is important to review patients periodi- cally to check that they are able to continue with the strategies effectively. Because of the progressive The physical therapist evaluates treatment outcome nature of PD it is important for patients to stay active. by testing it with respect to the treatment plan goals. Effects of physical activity aimed at improving bone On this basis, the treatment plan can be adjusted. The mass are visible only after a year (see the KNGF-guide- same outcome measures that were used during initial lines ‘Osteoporosis'). Therefore, the physical therapist assessment should be used for comparison. If the should encourage the patient to keep on exercising patient has difficulties communicating, the caregiver and moving after treatment has ended. The patient can help with evaluation of the treatment program.
can keep a diary in which frequency and extent of KNGF Guidelines for physical therapy in patients with Parkinson's disease exercise are recorded; the Borg scale can be used to also during the treatment period, the physical thera- measure the feeling of exertion during exercise (see pist informs the referring physician about, among other things, (individually determined) treatment An appointment for a review can be made to assess goals, treatment plan and treatment outcomes.
whether the effects of therapy have been maintained The physical therapist should write his final report or whether the patient has developed new problems. for the PCP or referring physician in accordance with If necessary, therapy can be restarted immediately the KNGF-guidelines entitled ‘Communicating with after the review. and reporting back to primary care physicians'. For the report contents, the guideline development group Final evaluation, conclusion and reporting
refers to the KNGF-guidelines entitled ‘Physical therapy The patient can be discharged from therapy when documentation and reporting'. The guideline devel- the treatment goals have been achieved or when the opment group recommends reporting if the patient physical therapist takes the view that physical thera- was treated according to the guidelines, on which py has no additional value. The patient may also be points, why treatment deviated from the guidelines discharged if the therapist expects him to be able to (if applicable), and if a follow-up appointment was achieve the treatment goals on his own (i.e. without therapeutic supervision). At discharge, but preferably KNGF Guidelines for physical therapy in patients with Parkinson's disease Review of the evidence impairments that may impede the exercise and use The evidence-based clinical practice guidelines by the of, for example, cognitive movement strategies. In Royal Dutch Society for Physical Therapy (KNGF) on the case of some disorders (e.g. PSP) reckless behavior Parkinson's disease are a guide for physical therapeu- may occur, due to which usually a limitation of activ- tic intervention in patients with PD. The diagnostic ities will have to take place. On the other hand, some and therapeutic processes are described conform to patients with another parkinsonism show particular the methodical physical therapeutic interventions. impairments or limitations that are similar to those of In this review of the evidence, choices made in these patients with PD. If these patients also have sufficient KNGF-guidelines ‘Parkinson's Disease' are underpinned mental function to comply with treatment, certain by the evidence and described in detail. Additional elements of these guidelines may be applied to them. information is also given. For the treatment of osteoporosis-related problems, The KNGF-guidelines should be considered as ‘the the guideline development group (see A.4.) refers to state of the art' for physical therapeutic intervention. the KNGF-guidelines ‘Osteoporosis'.4 These guidelines aim at optimizing the physical ther- Patients with PD reach their VO sooner than their apist's intervention according to the latest scientific healthy contemporaries5, but can, in the absence of literature, and according to current views within the severe cognitive problems, be trained in the same way as their contemporaries6. Therefore, general princi- ples of physical training are not discussed in these KNGF guidelines are defined as 'a systematic, Problems with writing and speech fall outside the centrally formulated and developed guide, which scope of the physical therapist. In the case of prob- has been developed by professionals and focuses lems with writing the patient should be referred to an on the context in which methodical physical occupational therapist. In the case of problems with therapy of certain health problems is applied, tak- speech, the patient should be referred to a speech ing into account the organization of the therapist. Micturation disorders should be referred to a pelvic floor physical therapist. Because of its spe- cialist character, this intervention is not described in these guidelines. Definition of the health problem
These guidelines describe the diagnostic and thera- A.2 Objectives
peutic process in patients with PD. The guidelines The objective of these guidelines are to describe are aimed at the treatment of patients with PD, who ‘optimal' physical therapeutic care for patients with have sufficient mental function to comply with treat- PD with respect to effectiveness, efficiency and tai- ment and show no other prominent health problems lored care, based on current scientific, professional, (co-morbidity). These KNGF-guidelines are not auto- and social views. This care has to lead to a complete matically applicable to other parkinsonisms, such as (or desired) level of activities and participation and multiple system atrophy (MSA) and progressive supra- has to prevent chronic complaints and recurrences. nuclear palsy (PSP). These parkinsonisms are char- Furthermore, these guidelines are explicitly meant acterized by a fast progression and a variable range to improve care based on current scientific evidence of additional neurological problems that are not and expert opinion; to stimulate uniformity and addressed in these guidelines (e.g. cerebellar ataxia quality of care; to define tasks and responsibilities of and spasticity). Furthermore, several parkinsonisms the professions, to provide insight into these tasks (e.g. PSP or vascular parkinsonism) are accompanied and responsibilities, and to stimulate co-operation by the appearance of, sometimes severe, cognitive between professions; to support the physical thera- KNGF Guidelines for physical therapy in patients with Parkinson's disease pist in deciding whether or not to treat and, if so, to with the ‘method to develop and implement guide- apply the best possible diagnostic and therapeutic lines'.1,2,7,8 In this method, among other things, practical instructions have been formulated for the Recommendations are formulated in terms of profes- strategy to gather literature. In the ‘Review of the evi- sional requirements, which are necessary in order to dence' of these guidelines the specific keywords, the apply these guidelines. sources consulted, the period in which the literature was collected, and the criteria to exclude or include A.3 Clinical
literature are reported. The members of the guideline The guideline development group that prepared these development group individually selected and graded guidelines looked for answers to the following clinical documentation, which was considered as scientific evidence. Although the scientific evidence was pre- 1. What specific health problems related to PD are pared individually or in small subgroups of members important for the physical therapist? of the guideline development group, the result was 2. What physical therapeutic diagnostic information discussed in the entire guideline development group. is necessary to be able to formulate the treatment The scientific evidence has been summarized in a objectives and a treatment plan? conclusion, including the extent of the evidence. 3. What forms of treatment and prevention have a Apart from scientific evidence, other aspects are of scientific basis and are useful? importance for the recommendations, including: 4. What forms of treatment need and prevention are reaching common consensus, efficiency (costs), avail- useful based on consensus of the guideline devel- ability of means, required expertise and education, organizational aspects and the desire to link with other uni- or multidisciplinary guidelines.
Formation of the guideline development
If no scientific evidence was available, recom- mendations were been formulated on the basis A guideline development group of experts was of consensus within the guideline development formed in December 2001 to answer the clinical group. A review panel of expert professionals (see G. questions outlined above. A balanced division of Acknowledgements) commented upon the recom- members was taken into consideration in forming the mendations. Once the draft mono-disciplinary guide- guideline development group, according to exper- lines were completed, they were sent to a secondary tise, experience and/or academic background. These guideline development group comprising external KNGF-guidelines were developed in cooperation with professionals or members of relevant professional the Dutch Society of Exercise Therapists according to organizations, or both, in order that a general consen- the methods of Mensendieck and Cesar (VvOCM). For sus could be achieved with other professional groups both professional organizations comparable guide- or organizations, and with other existing uni-discipli- lines for PD were developed in 2004. The guideline nary or multidisciplinary guidelines. In addition, the development group developed the first draft of the wishes and preferences of patients were taken into guidelines in a period of twelve months. During this account by means of a panel of patients (composed period an introductory meeting, two Delphi-rounds, by the Parkinson's Patient Society).
a newsgroup discussion, and several consensus meetings took place. All members of the guideline Validation by intended users
development group declared they had no conflicting The guidelines were systematically reviewed by interests regarding the development of the guide- intended users for the purpose of validation, prior to lines. Development of the guidelines took place from publication and distribution. The draft guidelines on December 2001 to December 2003.
PD were assessed by a group of fifty physical thera- pists, working in different settings. Physical thera- Procedure of the guideline development
pists' comments and criticisms were recorded and discussed by the guideline development group and, The guidelines have been developed in accordance if possible or desirable taken into account in the final KNGF Guidelines for physical therapy in patients with Parkinson's disease version of the guidelines. The recommendations on and limitations in activities; additional care and practice are derived from the available evidence, on treatment, including the need for occupational the other above-mentioned factors and on the evalua- and speech therapy input; advantages and disad- tion of the guidelines by intended users. vantages of aids.
• knowledge of skills with respect to: movement Formation of the steering group
examination and analysis, impairments in func- The development of the guidelines was guided as tions and limitations in activities; adequate treat- a process by the steering group, consisting of rep- ment techniques and possibilities; measurement resentatives of the KNGF (A. Verhoeven MSc and M. of clinical signs, such as determinants of diseases Heldoorn PhD, policy employees KNGF), and the and evaluation of the effectiveness of interven- Dutch Society for Physical Therapists in Geriatrics tions with the help of reliable and valid outcome (NVFG) (E. de Jong, secretary until September 2002; M. van Gennep, secretary from September 2002), the Dutch Society of Exercise Therapists according Physical therapists can obtain knowledge and skills to the methods of Mensendieck and Cesar VvOCM by studying and using the guidelines, and by follow- (Mrs. J. van Sonsbeek and Mrs. H. Verburg, national ing courses in which specific aspects with regard to quality officials), the Dutch Institute of Allied Health pathology, diagnostics and treatment of PD are dis- Care (NPi) (H.J.M. Hendriks PhD, senior scientist cussed (see appendix 2). and program manager ‘Guidelines Development & Implementation') and the Dutch Parkinson's Disease A.9.2 Referring
Association (P. Hoogendoorn MSc, chairman). These guidelines can also be used by referring physi- cians, to indicate the potential application of physical Structure, products and implementation of
therapy in the overall management of PD (see para- graph A.14). See paragraph B3 for an extensive over- The guidelines consist of three parts: the Practice view of the health problems for which patients can guidelines, the Review of the evidence, and a quick be referred to a physical therapist. reference card in plastic of the key points of the guidelines (the Summary). These parts of the guide- A.10 Reading
lines can be read separately and independently. The Physical therapists with no or little knowledge of PD guidelines were distributed in June 2004 through a are advised to start at paragraph A.12.
special issue of the Dutch Journal of Physical Therapy Physical therapists with sufficient knowledge of PD, on PD. The guidelines are implemented according to a but with little experience in treating patients with documented implementation strategy.1-3,7,8 PD, are advised to read the sections on diagnostic and A.9 Professional
Physical therapists with extensive knowledge of PD A.9.1 Physical
and large experience in the treatment of patients with The KNGF-guidelines can be used by all physical thera- PD, are advised to use these guidelines to evaluate pists, irrespective of the work situation. In order to their daily practice. be able to give optimal care to patients with PD, some advice is given regarding the furnishings of the prac- Evidence for the conclusions and
tice and available equipment (see appendix 4.15), recommendations
furthermore it is recommended that the physical Literature was collected using the electronic data- therapist has specific expertise. This specific expertise bases MEDLINE, CINAHL, PEDRO, EMBASE and the Cochrane library over the period of 1980 to 2003. Keywords • knowledge of, and insight in: recent develop- used in the search were ‘Parkinson's disease'. ments which have to do with neurology and Regarding interventions, this search strategy was developments in medical treatment; neuropsycho- combined with: ‘physiotherapy', ‘physical therapy', logical aspects; emerging impairments in function ‘physical therapy techniques', ‘exercise movement KNGF Guidelines for physical therapy in patients with Parkinson's disease Table 3. Grading of the level of evidence for intervention studies. meta-analyses (systematic reviews), which include at least some randomized clinical trials at quality level A2 that show consistent results across studies; randomized clinical trials of good methodological quality (randomized double-blind controlled studies) with sufficient power and consistency; randomized clinical trials of moderate methodological quality or with insufficient power, or other non-randomized, cohort or patient-control group study designs that involve inter-group comparisons; techniques', ‘training', ‘exercises', and ‘exercise For the interpretation of results found in the litera- therapy'. Regarding outcome measures this combina- ture, differences in the study designs were taken into tion was completed with: ‘sensitivity and specificity', account. The level of evidence for the studies that ‘exercise test', ‘physical examination', and ‘treatment were included were graded using criteria developed outcome'. Additional literature was collected from by the Evidence-Based Guidelines Meeting (EBRO plat- experts and secondary references in publications. The form), under the auspices of the Dutch Institute for guidelines are, as much as possible, based on the con- Health Care Improvement (CBO) (see table 3). These clusions found in randomized clinical trials (RCT's), judgment lists and criteria are compiled on the basis systematic reviews, and meta-analyses. The systematic of consensus for the development of guidelines in the reviews of Deane et al.9,10, the meta-analysis of De Goede et al.11 and the already published guidelines in Conclusions were drawn regarding the effectiveness Great Britain12 were valuable in this process. of separate interventions, which were based on the Some of the recommendations in the guidelines review of the literature and discussion of the guide- are based on consensus reached within the guide- line development group, and they were followed line development group. This is because from the by a recommendation (see table 4). When scien- literature available in April 2003 it was not possible tific evidence was derived from systematic reviews, to establish a generally accepted exercise program, meta-analyses, (randomized) clinical trials and study which was, with respect to form, content, intensity designs that involve inter-group comparisons, the and duration, fully based on qualitatively well-per- recommendations have been assigned a level 1, 2 or 3 formed studies.
qualification, depending on the evidence level. Table 4. Grading of the recommendations according to the level of evidence. Level of scientific evidence of the intervention
Description of conclusion or recommendation in
1. Supported by one systematic review at quality ‘It has been demonstrated that …' level A1 or at least two independent trials at qua- 2. Supported by at least two independent trials at ‘It is plausible that …' 3. Supported by one trial at quality level A2 or B, or ‘There are indications that …' research at quality level C 4. Based on the expert opinion (e.g. of working ‘The working group takes the view that …' KNGF Guidelines for physical therapy in patients with Parkinson's disease When scientific evidence is unavailable or unknown, but the subject is so important that inclusion in the The value of additional examination is very limited guidelines was preferred, the recommendations were in the case of PD. In patients with a characteristic made on the basis of consensus (level 4). Level 4 rec- presentation of the disease, a one-off scan, preferably ommendations were based on the opinion of (inter- using MRO (does not show abnormalities in the case of national) experts or on consensus within the guide- PD) may be useful.
line development group. Apart from health gain, side In the case of an atypical presentation of the disease, effects and risks were also considered when formulat- additional examination is useful to make an alterna- ing the recommendations. tive diagnosis more or less probable. The MRI-scan If no clinically relevant effect was demonstrated in shows, among other things, cerebro-vascular lesions. the available studies at level A, B or C, the recom- With SPECT- and PET-scans (Single Photon Emission mendation was formulated as ‘there is insufficient Computed Tomography and Positron Emission evidence that…'. Tomography, respectively) the functional integrity of the dopaminergic system in the striatum can be A.12 Parkinson's
judged; this can differentiate between the idiopathic A.12.1 Pathogenesis
form of PD and other forms of parkinsonism (espe- PD is a progressive neurological disorder.15 cially within the scope of scientific research). For an Degeneration of dopamine producing cells in the extensive overview of the cause, diagnosis and treat- substantia nigra (part of the basal ganglia) leads to ment of PD, see the treatment guidelines according to a decreased dopamine production. The first symp- toms of the disease become manifest when 60% to 80% of these cells are damaged.16 Because the cause of the damage is unknown, in the literature Based on the most recent population study, the it is also referred to as the idiopathic form of PD. Erasmus Rotterdam Health and Elderly (ERGO) study, Environmental factors17, such as exposure to pesti- the number of patients with PD in 1996 in the cides and, in patients who present with PD under 50 Netherlands was estimated to be 48,000 in the popu- years of age, genetic factors18 seem to play a role in lation of 55 years and older.22 In the Netherlands the cause of the disease.
the prevalence (approximately 1.4 % among persons older than 55 years) increases with age (55-64 years: 0.3%; > 95 years: 4.3%).22 There is no significant dif- PD can only be diagnosed with certainty post mortem, ference in the prevalence between men and women. if, with pathological anatomical tests, so-called Lewy Based on demographic developments, it is expected bodies can be demonstrated in the substantia nigra that the absolute number of patients with Parkinson's and other pigmented nuclei of the brain.19,20 disease in the Netherlands will rise to almost 70,000 Ten to twenty percent of patients have another diag- in the year 2015.23 The incidence of Parkinson's dis- nosis on post mortem examination, for example MSA ease in the Netherlands, standardized to the Dutch and PSP, parkinsonism caused by medication and population in 2000, is estimated at 7,900 patients vascular parkinsonism. Using the criteria of the Brain Bank of the UK PD Society, 19 only a probable diagno- sis can be made.
A.12.3 Consequences of Parkinson's disease
The clinical diagnosis of ‘PD' is made if there is brady- To describe the health problems which are a con- kinesia accompanied by at least one of the following sequence of PD, the guideline development group disorders: 1) rigidity of the muscles; 2) rest tremor (4- made use of the ‘International Classification of 6 Hz); 3) balance impairments that are not caused by Functioning, Disability and Health'.25 Figure 1 primary visual, vestibular, cerebellar or proprioceptive presents a global overview of the health problems connected with PD and the factors influencing these KNGF Guidelines for physical therapy in patients with Parkinson's disease Figure 1. Global overview of impairments, limitations and participation restrictions associated with Parkinson's disease (adapted from the diagram published by Kamsma, 2002). Parkinson's disease: dysfunction of the basal ganglia, caused by degeneration of dopamine-producing
cells in the substantia nigra (ICD-10: G20)1
Functions
Activities
Primary impairments:
Secondary impairments:
Limitations in:2
Participation problems in:
• musculoskeletal system; • musculoskeletal system; • mobility, such as • interpersonal interactions • cardio-vascular system; transfers and changing and relationships; • sensory functions; • respiratory system; • education, work and • mental functions; (maintaining body • digestive tract; • mental functions; position), reaching and • self-care and domestic • uro-genital functions; • digestive tract; grasping and gait; • sleeping functions. • uro-genital functions; • other activities, such as • community, social and • sleeping functions. household activities. civic life.
External factors (positive and negative), such as
Personal factors (with positive and negative influences
on functioning as a whole, and with that on the quality
• attitudes, support and relationships (among others, of life) such as:
partner, primary care physician, employer); • accommodation (e.g. furnishing, housing type); • education, work and employment (kind, • socio-cultural background; circumstances, conditions and relations).
• habits in exercising; • attitude (e.g. in relation to work); 1 Code of the International Classification of Diseases.
2 Limitations in activities to different gradations, until full independence.
Impairments in functions and limitations in
Consequences of health problems relevant to physi- cal therapy are within the domains of (in arbitrary As a (direct) consequence of PD, or as a consequence order): transfers, body posture, reaching and grasping, of the medication used or inactivity, impairments balance and gait (see table 6).
may arise in the function of the musculoskeletal system, the cardiovascular system, the respiratory sys- tem, pain, sensation and mental function (see table KNGF Guidelines for physical therapy in patients with Parkinson's disease Table 5. Overview of the impairments that link with PD. Problems in the cells printed in green fall within the scope of the physical therapist. Musculoskeletal system,
Pain and sensory
Mental functions
cardiovascular system,
functions
respiratory system
• Body posture: • pain in the musculo- • fear of falling or • sleeping problems - generalized change caused by problems in posture towards - due to postural with rolling over bed flexion, often in combination with reactions of posture • gait pattern: reduced • pain in the gastroin- • sleeping problems by stride length, height, testinal tract(med.): a different cause: and speed, trunk rota- - due to constipation, tion and arm swing, caused by decreased - shortened REM sleep - dystonic posturing: moving delayed and quality affected by - excessive daytime rigidity, bradykine- sia, akinesia (free- - facial hypokinesia • insufficient muscle • neck- and en occipital • digestive and function (strength, especially in geriatric stamina) and length - perseverance of - constipation and soiling (leaking of fluid from the - hypersexualiteit(med.) KNGF Guidelines for physical therapy in patients with Parkinson's disease Musculoskeletal system,
Pain and sensory
Mental functions
cardiovascular system,
functions
• insufficient mobility • central pain (from • hallucinations(med.) • voice and speech the CNS): a vague, - extent to which the general feeling from speech is fluent and tension to pain, espe- cially occurring in young patients with - palilalia (repetition Parkinson's disease; in of words or senten- that half of the body that is most impaired with regard to motor • insufficient stamina • restless legs: unplea- • higher cognitive Functions of the skin sant or even painful • Sweating (too much feeling in the legs during inactivity (for • Increased activity of example when falling the sebaceous gland asleep), sometimes causing a greasy skin decreased by moving (walking) and stimu-lating (rubbing, hot shower) • dystonia, especially in • mood alterations hypotension(med.), lia- the feet, particularly during the off-period - response fluctuati- (therefore also early in ons*, such as: wea- the morning) because ring off; on/off-pro- the effect of medica- blems; dyskinesia; tion has worn off freezing or dystonic • pins and needles • loss of initiative • deviating sensibility • deterioration of atten- • decreased smell • limited internal imagi- nation of visuo-spatial stimuli • personality changes * In these problems the physical therapist has an advisory task, although treatment of the problem falls outside the scope of the physical therapist; (med.): problems which are (partly) caused by medication. KNGF Guidelines for physical therapy in patients with Parkinson's disease processing sensory information, which might aggra- The performance of transfers, such as rising from a vate balance problems.42 chair and sitting down, getting in or out of bed, and turning over in bed are limited.27-29 Patients are espe- cially limited in the performance of transfers in the The gait pattern of patients with PD is often character- advanced stages of the disease.30 ized by a reduced stride length and height, walking speed, rotation of the trunk, and arm swing.43-47 At Body posture equal walking speeds, step frequency in patients is Body posture in patients with PD is characterized by a increased compared to that of healthy contemporar- generalized change in posture towards flexion, often ies.48 The abnormal gait pattern is increased dur- in combination with latero-flexion. These postural ing dual tasking49, and festination and freezing can problems can lead to pain in the musculoskeletal sys- occur50. Festination and freezing occur especially dur- tem. The cause of the postural problems is unknown. ing attempts to start walking (hesitation), while pass- The generalized change in posture towards flexion ing narrow spaces, such as a doorway, during rotating may be one of the causes of (recurrent) falling. movements, and during performance of dual tasks Secondary muscle weakness of, particularly, the back while walking. Especially in patients who frequently and neck extensors may arise, but also of the muscles freeze during walking, variability of stride length is of the shoulders (adductors), hip (extensors), buttocks and legs (extensors). A temporary change in posture towards flexion, on the other hand, might be func- tional if it is meant as a ‘cue' to be able to start mov- Patients with PD tend to be inactive.53 This may partly ing. In addition to the generalized change in posture be due to fear to move or fear to fall. Through inac- towards flexion, reduced trunk flexibility can arise tivity, secondary disorders may arise, which include as a consequence of rigidity and bradykinesia.31,32 decreased aerobic capacity, decreased muscle func- Reduced trunk flexibility can cause problems in pre- tion (muscle strength, length and stamina), decreased serving balance and performing activities, such as mobility of joints, and decreased bone quality (oste- oporosis). Furthermore, inactivity might lead to gas- tro-intestinal dysfunctions (e.g. constipation). Reaching and grasping Reaching, grasping, manipulating and replacing objects is often disturbed, causing problems while PD is a predisposing factor for falls.54-57 Patients with performing compound, complex activities, such as PD have, compared to their contemporaries, a two58 getting dressed and eating. In relation to station- to six59 times greater chance of falling ‘once' and a ary objects, speed and joint mobility are reduced. nine times greater chance of recurrent falls59. The Furthermore, the grasping forces used are high, cause of these falls is most often intrinsic in nature, especially in the execution of precision tasks of low such as problems with posture and balance (especially weight objects.33 Moving objects (e.g. a coin rolling during turning, rising from a chair and bending for- away) on the contrary, seem to work as an external ward), freezing, orthostatic hypotension, and neuro- cue to normalize grasping.34 logical or cardiovascular co-morbidity.59,60 Extrinsic factors, such as doorsteps and bad lighting, play a much smaller role. In combination with the increased Preserving balance is a major problem for many chance of osteoporosis, falling can lead to fractures or patients with PD.35,36 Disturbed postural reflexes cause to other physical injuries.58,61 Patients with PD often balance problems. The amplitude of these reflexes fall forward.62 In comparison with ‘healthy' elderly is abnormal.37,38 Furthermore the reflexes are not less fractures of the wrist occur in patients with PD, adjusted to the actual circumstances of the patient.39- since these patients break their falls to a lesser extent 41 Probably akinesia, bradykinesia and rigidity are with the outstretched hand. The problems of falling responsible for this. Patients with PD have problems can lead to loss of independence or admission into a KNGF Guidelines for physical therapy in patients with Parkinson's disease Table 6. Limitations in activities. Transfers: starting and performing complex movements with risk of falling, for example:
• sitting down and rising; • getting in or out of a car; • getting in or out of bed; • turning in bed; • getting on or off a bicycle or home-trainer.
Posture: increasing generalized change in posture towards flexion.
Reaching and grabbing:
• personal care, such as toileting and getting dressed, especially buttoning up; • household activities, such as: - brushing teeth; • problems with writing (micrographia); Balance: tendency to propulsion with risk of falling, especially during:
• performing transfers; • changing body position; • walking (climbing stairs); • turning.
• starting, stopping and turning around; • freezing at the start of walking or during walking, with risk of falling; • problems with dual tasking* with risk of falling; • obstacles, for example: • long distances.
* Dual tasking means the simultaneous execution of two motor tasks or a cognitive and a motor task. nursing home.63 Moreover, it can decrease the quality may even increase the likelihood of a fall occurring of life considerably.64 Predictors of falls are: falls in – both because of increased mobility and because the the past year, a decreased arm swing during walking, medication can cause dyskinesias, freezing or ortho- dementia, and a long sickness period.58 In the case of static hypotension.59 As a consequence of (near) fall- two or more falls in the previous year, patients with ing, patients can develop fear to move (fear to walk, PD have a very high liability to fall again within the fear of making transfers). Inability to stand up and next three months.65 A history of two or more falls knowing that falling can cause a (hip) fracture play a had a sensitivity of 86.4% (95% CI 67.3-96.2%) and a role in the onset and preservation of this fear.
specificity of 85.7% (95% CI 71.2-94.2%) in predicting a fall in the next 3 months. Anti-Parkinsonian medi- cation usually has little or no influence on the pos- In the treatment of patients with PD, mental impair- tural problems and impaired balance.36,37 Medication ments reduce the potential for a successful outcome KNGF Guidelines for physical therapy in patients with Parkinson's disease of treatment and the ability to use strategies. Patients problems (swallowing problems). Patients with PD have problems with spontaneously changing strategy have a life expectation similar to their contemporar- (set shifting), with memory, and with choosing the right strategy in case of varying stimuli and circum- The severity of the disease is often classified accord- stances (cognitive inflexibility). Furthermore, they ing to the (modified) classification of Hoehn and Yahr may suffer from complex behavioral disorders, sleep- (see table 7).76 However, this classification is only a ing problems, psychotic behavior and dementia.66 rough one, with large variability, especially in stage 1. Besides, the use of medication can cause cognitive Furthermore, a patient can be classified in two stages, impairments, such as depression, confusion, memory depending on whether the patient is on the on- or defects, and visual hallucinations (see appendix 3).
off period (e.g. during the on-period in stage 2 of the Hoehn and Yahr classification and during the off-pe- riod in stage 4 of the Hoehn and Yahr classification).
Problems with participation can occur in the area of social relations, work, hobby, and sports in patients A.12.5 Prognostic
Jankovic et al. distinguish tremor-dominant and aki- netic-rigid types of PD.77 A.12.4 Natural course of the complaints
In the akinetic-rigid patients, rigidity and hypokinesia Relatively little is known about the natural course of are the initial symptoms. This group is characterized PD. Although always progressive, the natural course is by problems with balance and gait (including freez- very variable.67 The first symptoms are usually uni- ing).78 Besides that, these patients show a more rapid lateral.21 Around three years after the first symptoms course of the disease (among others in the motor and present, it typically develops into a bilateral disorder, cognitive areas).77 In case of comorbid arteriosclerosis usually still with intact balance.68 Problems with bal- the prognosis seems even worse.79 ance develop about two to three years later, although In the tremor-dominant group the process often some patients reach this stage only seventeen years develops more slowly79-81 and dementia80 and cogni- after the start of the disease.68 Recurrent falling starts tive impairments81 occur less frequently. on average ten years after the first symptoms.69 In patients who are diagnosed at a young age, the Eventually, nearly all patients will have impaired bal- cognitive functions and postural reflexes often ance and will fall repeatedly. This forms a threat to remain unimpaired for a long time.77,82 For patients quality of life.70 Initially, patients with balance prob- with recurrent falls, and for patients with insufficient lems can stand and walk on their own, but on aver- physical activity, the prognosis is unfavorable.83 The age after eight years, falling becomes, in combination guideline development group takes the view that with the other symptoms, a more severe problem. physical inactivity and falling are prognostic fac- Eventually the balance impairment can become so tors which can be positively influenced by physical severe that the patient is permanently confined to a wheelchair or bed, if he has no help of others. Less than five percent of patients with PD are confined to a wheelchair or bed eventually.71 In later stages non- The general treatment goal is to optimize the daily motor symptoms may arise, such as dementia.
functioning and to prevent secondary complications. In geriatric patients PD is often accompanied by Different medical and paramedical treatments can be depression. Furthermore the health problems of used to achieve this.15 these patients can be complex due to age-related co-morbidities. Patients living independently in the community as well as in nursing homes, often die Treatment with medication of (aspiration) pneumonia, heart failure72,73, sepsis The limitations the patient with PD presents will due to infection in the urogenital tract, or complica- determine when and what type of medication will be tions after pressure sores and falling74,75. Aspiration started.15 See appendix 3 for an overview of possible pneumonia is often the direct cause of primary health medication. As a rule, medication is only started if KNGF Guidelines for physical therapy in patients with Parkinson's disease patients are unable to perform their work or hobbies levodopa. A MAO-B inhibitor (Eldepryl®) is also often well because of the complaints, or if the mobility of used in an early stage of the disease, or in combina- the patients is affected. Sometimes, in addition to the tion with other medicines.
medication, surgical intervention as indicated takes Anticholinergics (Artane®, Akineton®) have a positive effect on resting tremor, by restoring the impaired Medication options are:21,84,85 balance between the substance acetylcholine and dopamine in the brain. Just as amantadine, the anti- cholinergics cause a lot of side-effects in geriatric patients. Therefore, this medication is prescribed less • anticholinergics; among these patients.
• levodopa.
Most effective is levopoda (Sinemet®, Madopar®), a substance that is transformed in the brain into If the symptoms are mild, sometimes treatment dopamine; this way the shortage of dopamine is is started with amantadine (Symmetrel®), which supplied. In view of the unfavorable effects in case reduces hypokinesia and rigidity. Besides, amantadine of long term usage, prescription of levopoda is post- can be prescribed to reduce dyskinesias. The working poned for as long as possible. Not all the major symp- mechanism of this is unclear. In geriatric patients, toms of PD react equally well to the dopaminergic amantadine causes a lot of side-effects and is there- treatment. The effect on bradykinesia and rigidity is fore prescribed less often. often good, the effect on the resting tremor is varia- Because amantadine is limited in its effectiveness in ble, and the effect on the impaired postural reflexes is treating symptoms of PD, dopaminergic medication limited. In combination with levopoda, the substance is often commenced. Dopamine agonists (Parlodel®, entacapone (Comtan®) is often prescribed. This sub- Permax®, Requip®, Sifrol®) are the first choice, espe- stance inhibits the breaking down of levopoda and by cially for younger adults. This medication stimulates doing so it makes the treatment more effective. (for the greater part), the postsynaptic dopamine In case of long term usage of levopoda (longer than receptors in the striatum), just as dopamine does; by 2 to 5 years) the wearing-off phenomenon starts tak- doing so it imitates the natural substance dopamine. ing place; when this happens the frequency and the In some cases, they are already prescribed in the first dose of the separate substances need to be increased phase of the disease, or later, in combination with to retain a constant effect. Furthermore, patients have Table 7. Classification according to Hoehn and Yahr. Not disabling, mild, unilateral symptoms (e.g. tremor, posture, locomotion, and facial expression).
Bilateral involvement, without impairment of balance. Possibly already a light kyphotic posture, slow- ness and speech problems. Postural reflexes are still intact. Significant slowing of body movements, moderate to severe symptoms, postural instability (no reco- very on the Retropulsion test*), walking is impaired, but still possible without help, physically inde- Severe symptoms, rigidity and bradykinesia, partly disabled, walking is impaired, but still possible wit- Fully disabled, walking and standing impossible without help, continuous nursing care is necessary. * The working group defines recovery as: 'the patient recovers by himself and needs a maximum of two steps. KNGF Guidelines for physical therapy in patients with Parkinson's disease to deal with the on- and off-problems. In case of long formed Cochrane reviews the authors concluded that, term usage of levopoda freezing can occur during until now, there is insufficient evidence for the effec- both on- and off-periods. Furthermore, the (long term) tiveness of exercise therapy, and the preference of one usage of levopoda might lead to neuropsychiatric form of exercise therapy over another.9 In a third sys- complications, dyskinesias, and sudden and unpre- tematic review (meta-analysis), which included RCT's dictable variation in the on- and off-periods. If an off- and matched controlled trials, the authors concluded period occurs suddenly in a patient, an apo-morphine that physical therapy or exercise therapy has a posi- pump (dopamine agonist) is sometimes preferred.
tive effect on gait (speed and stride length) and on performance of activities in daily life.11 Through stereo-tactic interventions parts of the basal ganglia can be ruled out by a lesion (-tomy) or Occupational therapy aims to solve practical prob- stimulation via high frequency electro-stimulation.21 lems arising in daily activities, for example in the Possible target areas for the intervention are the area of living, work, hobby and recreation, self- globus pallidus, the subthalamic nucleus (STN) and care, transport, housekeeping and communication. the thalamus. Depending on the target area such an Examination and treatment focus on: an optimal intervention causes in particular a decrease of dys- planning of activities during the day; carrying out kinesias (pallidotomy) or tremor (stimulation of the activities, if needed in a different manner; coping thalamus or subthalamic nuclei). The interventions with freezing; learning (the use of) ergonomic prin- applied most often are unilateral pallidotomy and ciples. Furthermore the occupational therapist has bilateral STN-stimulation. an advisory role in the purchase and use of aids and Stimulation of the basal ganglia can take place uni- facilities, and in adjusting the home environment laterally or bilaterally, but it is mostly done unilateral and the interior of the house in such a way that ADL because of the risk of complications. Stimulation can be performed more easily. The occupational ther- takes place by connecting an electrode in the brain to apist gives instructions to the caregiver*. In a recent a pacemaker. Complications might occur as a conse- Cochrane review it was concluded that there is still insufficient evidence for the effectiveness of occupa- • the intervention itself (by damaging the surround- tional therapy in patients with PD.86 • the applied equipment (e.g. infections); Speech therapy • the lesions or stimulation (among others falling Speech therapy aims at teaching the patient to cope problems, paraesthesia, and headache). with, or to decrease, the limitations and participation problems, which are connected with communication, Allied health policy
eating and drinking. Examination and treatment In addition1 to medication treatment and (possible) focus is on: motor skills of the mouth, swallowing, surgical treatment, treatment by allied health profes- breathing, posture, mimics, articulation and intona- sionals is possible.21,35 Most important interventions tion, tempo and rhythm of speech, and on the use of are physical therapy, exercise therapy Cesar, exercise alternative communication aids (e.g. computer, com- therapy Mensendieck, occupational therapy, and municator). In two recent Cochrane reviews it was speech therapy.
concluded that for patients with PD with dysarthria, despite the described improvement of the speech Physical therapy disorders, there is insufficient evidence for the effec- The objective of physical therapy for PD is to improve tiveness of speech therapy and the preference of one the quality of life by improving or preserving inde- form of speech therapy over another.87 pendence, safety and well-being through exercise. In a number of intervention studies the effectiveness of physical therapy in PD was studied. This did not lead, When a patient's needs are complex, a multidisci- however, to unequivocal conclusions. In recently per- plinary treatment is indicated. A multidisciplinary The term caregiver refers to both the partner and any other person who takes care of the patient. KNGF Guidelines for physical therapy in patients with Parkinson's disease team may include, in arbitrary order, a neurologist, classification, classified in stages 1 to 2.5. The goal of a rehabilitation physician, a primary care physician, physical therapy in this and the following phases is: a nursing physician, a physical therapist, an exercise 1. prevention of inactivity; therapist, an occupational therapist, a speech thera- 2. prevention of the fear to move or to fall; pist, a (neuro)psychologist, a recreational activities 3. preserving or improving physical capacity (aerobic supervisor or an occupational therapist (especially in capacity, muscle strength, and joint mobility). case of relatively young patients), a social worker, and a PD specialist nurse. The means by which the physical therapist can It is necessary that all different disciplines treating a achieve these goals are by giving information and patient communicate with each other. Most often the advice, and by (group) exercise therapy, with specific neurologist, the (PD) nurse, or the rehabilitation phy- attention to balance and physical capacity. sician will act as team coordinator, but this depends on the regional organization of health care. In the A.13.2 Physical therapy in the mid phase
Netherlands there is, at the moment, the possibility In the mid phase, patients develop more severe of a so-called Short Stay, or multidisciplinary reha- symptoms and limitations in activities. In addition, bilitation in day care, in a number of locations (see problems with balance arise, with an increased risk of falling as a consequence. In this phase patients are classified in the stages 2 to 4 according to the Admission to a nursing home Hoehn and Yahr classification. The goal of the physi- The main reasons for referral to a nursing home are cal therapist in this and in later phases is to preserve physical decline and falling problems, especially if or improve activities. This is achieved by exercis- these are accompanied with confusion and increasing ing function and activities (by exercise therapy). In dementia.63 Sometimes (temporary or permanent) treatment, which is preferably given at the patient's admission to a nursing home or related forms of care home, five core areas can be identified: are indicated although there are no (or only minimal) physical or psychological complaints.88 This occurs mostly where there are problems related to the home 3. reaching and grasping; circumstances (e.g. the temporary lack of a caregiver).
The role of the physical therapist
The objective of the physical therapist for PD is to Cognitive movement strategies and cueing strategies improve the quality of life by improving or maintain- are applied. If necessary the caregiver will be involved ing the patient's independence, safety and well-being in the treatment.
through exercise. This is achieved by prevention of inactivity, prevention of falls, improving functions A.13.3 Physical therapy in the late phase
and decreasing limitations in activities. Based on In this phase of the disease the patient is classified the phases the patient goes through, treatment goals in stage 5 according to the Hoehn and Yahr classi- with accompanying interventions can be determined. fication. The patient is confined to a wheelchair or Quick reference card 3 describes the different phases bed. The treatment goal in this phase is to preserve the patient goes through with a number of specific vital functions and to prevent complications, such treatment goals for each phase. These treatment goals as pressure sores and contractures. This is achieved apply to the phase addressed, but also remain impor- by actively supported exercising, correcting the body tant in later phases. Quick reference card 3 is based posture in bed or in the wheelchair, and by giving on studies of Turnbull89 and Kamsma26. information and advice with regard to the prevention of pressure sores and contractures. In this therapy, the A.13.1 Physical therapy in the early phase
caregiver will be involved.
Patients in the early phase of PD have little or no limi- tations. They are, according to the Hoehn and Yahr KNGF Guidelines for physical therapy in patients with Parkinson's disease the physical therapist if other forms of parkinsonism A.14.1 Setting
Indication
are excluded. It is desirable that the physical thera- The guideline development group takes the view that pist receives information, preferably by a copy of the physical therapy treatment is indicated in case of the medical correspondence, on the course of the health following impairments or limitations:12,90,91 problems, on possible mental disorders of the patient • restrictions in activities and impairments in func- related to PD, on the treatment policy, and on the tions especially with respect to transfers, body result of past and ongoing other treatments. posture, reaching and grasping, balance and gait; • inactivity or a decreased physical capacity; B Diagnostic
• increased risk to fall or fear to fall; During the diagnostic process the physical therapist • increased liability to pressure sores; determines if physical therapy is indicated and if • impairments and limitations as a result of neck these guidelines can be applied to the patient con- and shoulder complaints; cerned. The diagnostic process consists of taking • need for information about the consequence of the medical history, analysis of the medical history, PD, especially regarding those limitations in activi- performing a physical examination and drawing up a ties which have to do with posture or movement.
treatment plan. The starting point for the diagnostic process is the patient's request (including the most When related to the patient's limitations in activities, the caregiver's needs can also be a reason for referral The physical therapist assesses purposively, consci- (e.g. lifting instruction in case the patient is confined entiously, systematically and methodically (module to a wheelchair or bed).
Methodical Conduct of Physical Therapy Diagnosis and Intervention KNGF94) which impairments (in A.14.2 Early
functions), limitations in activities (disabilities) and Early referral (immediately after diagnosis) to a physi- participation problems are of most immediate con- cal therapist is recommended to prevent or decrease cern to the patient. He assesses the prognosis, and the complications as a result of falling and inactivity.90- patient's needs for information.
92 This is in line with the recommendation in the ‘Guidelines diagnostics and treatment of patients B.1 Referral
with PD' of the Commission Quality Promotion of the If a patient is referred by a primary care physician Dutch Society for Neurology.15 (PCP) or medical specialist, the physical therapist assesses whether the referral contains sufficient infor- A.14.3 Providing
mation (see paragraph A.14.3). The physical therapist needs the following informa- The objective of the diagnostic process is to assess the tion from the referring Physician:93 severity and nature of the patient's problems, and to • name, date of birth and address of the patient; evaluate the extent to which physical therapy can influence these problems. The starting point is the patient's own goal. It is necessary that the physical • co-morbidity (including osteoporosis and mobil- therapist receives information on possible co-morbid- ity-limiting disorders such as arthritis, rheumatoid ity (among others osteoporosis or other disorders that arthritis, heart failure and COPD); decrease the mobility, such as arthritis, rheumatoid • course of the health problem; treatment policy arthritis, heart failure and COPD). Furthermore it is until now and its result (preferably a copy of the important for the physical therapist to know if other medical correspondence); forms of parkinsonism are excluded. Information • reason for referral (patient's request or the objec- should be received on the disease course, on possible tive that the referring physician wants to achieve mental impairments related to PD, on treatment poli- with the referral); cy, and on the results of medical treatment thus far.
• name, address, and signature of the physician.
Furthermore the referring physician should inform KNGF Guidelines for physical therapy in patients with Parkinson's disease tifying health problems and evaluating the effects of While taking the medical history the physical thera- treatment in groups of patients with PD. The value of pist asks questions which are necessary to determine these instruments for use with individual patients is the patient's problems (see quick reference card 1). still unclear. The guideline development group select- Also the patient's expectations regarding the inter- ed outcome measures which seemed to be most suit- ventions and treatment outcome are recorded. The able for use in daily practice. In this selection process, physical therapist tries to assess whether the patient's clinimetric properties were of a decisive nature. The expectations are realistic. When mental factors or guideline development group takes the view that for physical disorders result in communication difficul- this purpose outcome measures linked to the level of ties, and when the patient is mainly dependent on limitations (in activities) domain of the International others for care, it is necessary to involve the caregiver Classification of Functioning, Disability and Health to get an accurate picture of the patient's problems. (ICF) are most suitable.25 Based on the history-taking, the physical therapist The guideline development group makes a distinction formulates treatment goals, together with the patient.
between outcome measures that should always be used, and outcome measures that can be used in addi- Analysis to formulate the objectives to be
tion, dependent on the treatment goal. As a result of medication, motor problems can vary Based on the information obtained while taking the greatly during the day. Therefore it is important that medical history, the physical therapist formulates a measurements are performed at the same time of the number of problems to be tested in a physical exami- day, assuming medication intake takes place at the nation. Possible objectives are: 1) physical capacity; 2) same time each day.
transfers; 3) body posture; 4) reaching and grasping, and 5) balance and gait.
Questionnaire Patient Specific Complaints
In order to objectively identify and evaluate the B.4 Physical
Examination
extent of limitations in most important activities, the The health problems of patients with PD can vary guideline development group recommends the use widely during the day. Therefore, during physical of the Patient Specific Complaints questionnaire, a examination, the physical therapist should determine patient preference outcome scale (see appendix 4.1). if the patient is in an on- or off-period. The physical The Patient Specific Complaints questionnaire is a therapist can make use of quick reference card 2 as measuring instrument to determine the functional a guide to perform a structured physical examina- status of individual patients.95 It lists the limitations tion of ‘physical capacity', ‘transfers', ‘body posture', (and participation problems) frequently encountered ‘reaching and grasping', ‘balance', and ‘gait'. Based in daily life and perceived by the patient as being on the medical history the physical therapist deter- important. For this reason the questionnaire is suit- mines if the patient has other disorders that need to able to specify and evaluate individual treatment be included when physical examination is performed goals. in the case of patients with low back pain, it (e.g. neck-shoulder complaints or back complaints can distinguish between patients with and without that seem to be connected with PD).
progress and demonstrates responsiveness. In this patient population the Patient Specific Complaints B.5 Outcome
questionnaire is responsive.95 Outcome measures serve as an aid in charting and Patients select the five most important complaints objectively assessing health problems. Furthermore, a regarding their physical activities they would like to number of outcome measures can be used to evaluate improve. The activities have to be relevant for the (preliminary) treatment effectiveness. A broad range patient personally, have to be carried out periodically of outcome measures is available to identify and (weekly), and have to be inevitable. At follow up the evaluate health problems related to PD. The majority patient must have performed the activity again, so of these instruments, however, is developed for the that a follow-up measurement can take place. For benefit of scientific research and is focused on iden- each activity the patient indicates how troublesome KNGF Guidelines for physical therapy in patients with Parkinson's disease it was to carry out that activity in the foregoing week fied (range 0 to 3). on a Visual Analogue Scale (VAS) of 100 mm. The score The range of the total score is 0 to 30. In a popula- is the distance in millimeters from zero (left side of tion of elderly still living at home (55-85 years of the line) to the mark the patient set. The three most age) a score of 3 or more in the modified FES (patient difficult activities can be evaluated. For external has fear to fall), especially in combination with more communication a total score can be determined by than one fall in the past year, is a good predictor for adding up the scores of the three most difficult activi- recurrent falling.99 Currently it is unknown to what ties. At the beginning and at the end of the treat- extent these data can be applied to patients with PD. ment period the patient indicates how hard it was to The original FES has been found to be reliable and perform these three activities in the foregoing week. valid in a population of elderly living at home.100,101 With the follow-up measurement preceding score is Furthermore, it appeared responsive for ‘improve- shown to the patient.
ment after rehabilitation' in a population of stroke The VAS is easily understood by most patients from patients in the first period after stroke.102 diverse cultural groups and can be used frequently and repeatedly. The use of the VAS requires no specific Freezing of Gait questionnaire
During physical examination it is difficult to score freezing, because it occurs rarely during the clini- Questionnaire History of Falling
cal assessment.30 Physical therapists are especially Patients with PD who have fallen more than once in dependent on the patient's self-report. If patients a year, have a very high liability to fall again within have recently experienced that their feet were glued the next three months.65 Incidence of falling and or stuck to the ground, the physical therapist asks the the possible risk of falling are mapped by means of a patients to fill in the six questions of the Freezing of short structured questionnaire – the History of Falling Gait questionnaire (FOG questionnaire; see appendix questionnaire (see appendix 4.2).96,97 Patients who 4.6).103 This instrument is suitable to identify freezing fell more than once in a year receive a falls diary (see in a population of patients with PD.103 appendix 4.3). The falls diary gives insight into the frequency and circumstances of falling. The falls diary LASA physical activity questionnaire
is very extensive, but it concerns a severe and trouble- If there are doubts with respect to the patient's level some problem. It is recommended to ask the caregiver of activities (Dutch Standard of Healthy Moving)104, to fill in the falls diary together with the patient.
the guideline development group advises the use of the LASA physical activity questionnaire (LAPAQ; see (Modified) Falls Efficacy Scale
appendix 4.7).105 The LAPAQ is a valid and reliable Confidence in maintaining balance (preserving method to measure physical activity of the elderly body posture) seems to be a mediator in the elderly and is easier to use than instruments like a seven days between the fear to fall and functional ability.98 If activity diary or a pedometer. The time needed to patients have fallen in the past year, or if there have complete the LAPAQ is about six minutes.
been moments that they almost fell, it is necessary to identify the fear to fall objectively. The (modi- Based on the above the guideline development
fied) Falls Efficacy Scale is an extensive test in which group formulated the following recommendations:
patients are asked about the fear to fall (‘none' to ‘a lot'), they experience during the performance of ten Inventory (and objective evaluation) of the most
different activities (FES; see appendix 4.4).99 In this important problems during history-taking (level
test some items in the original FES, namely ‘getting 4)
in and out of bed', ‘personal grooming', and ‘getting The guideline development group takes the view that on and off the toilet without falling' are replaced by the Patient Specific Complaints Questionnaire (for ‘cleaning the house, such as sweeping and dusting', patient specific complaints in the performance of ‘doing simple shopping', and ‘climbing up and down activities and assessment of the treatment goal) and the stairs'. Furthermore the scoring system is simpli- the History of Falling Questionnaire (retrospective) KNGF Guidelines for physical therapy in patients with Parkinson's disease should be used when taking the medical history of a B.5.9 Six-minute
patient with PD. Patients with PD have a tendency to be inactive. To identify and evaluate the physical capacity of patients Inventory of freezing during history-taking (level
who are not troubled by freezing, it is recommended that the Six-minute walk test is performed (see appen- The guideline development group takes the view dix 4.8).111 This test is functional, easy to apply, and that the FOG questionnaire should be used in patients reliable for this group of patients.112 Furthermore the with PD who have recently experienced that their feet Six-minute walk test can detect changes within this seemed glued or stuck to the ground.
population (which are the result of training).113 If the test is performed in a marked out, square track, the Inventory and evaluation of falling or near falling
physical therapist should not walk together with the patient.114 If the test is performed on a treadmill the The guideline development group takes the view that, inclination grade has to be zero and, if indicated by if patients with PD have fallen in the past year, or if the patient, the speed can be increased (this should they have experienced near falls, the FES and (prospec- not be done by the patient himself).115 It is important tive) falls diary should be used to identify and evalu- that the patient wears the same footwear for each ate these problems.
assessment110 and that the physical therapist encour- ages the patient to the same extent114. B.5.6 Retropulsion
Numerous tests are available to assess balance pro- B.5.10 Ten-meter walk test
blems, but none of them measure the whole spec- The Ten-meter walk test is a reliable instrument to trum of balance reactions. The most used, quick and identify the comfortable walking speed of patients easy to perform test is the Retropulsion test, by which with PD who are able to walk independently (see an unexpected, quick and firm jerk on the shoulder is appendix 4.9).112 Furthermore, the number of steps given in a backward direction (see appendix 4.5).106 needed to walk ten meters at a comfortable pace is Currently this test seems the most reliable and valid used to determine the stride length (in connection test by which to assess balance in patients with PD. with the possible use of visual cues). During the per- formance of the test a walking aid may be used if Parkinson's Activity Scale
The Parkinson's Activity Scale (PAS) can be used to assess problems with functional mobility.107 In the Based on the above the guideline development
modified version of the PAS, the item gait-akinesia is group formulated the following recommendation:
extended with two dual tasks (see appendix 4.10). The PAS is a comprehensive practical test for gait Objective inventory and evaluation of complaints
and transfers (including rolling over in bed). It takes around ten to fifteen minutes to administer. The test The guideline development group takes the view is a valid and reliable instrument for patients with PD that during physical examination of patients with PD and gives relevant information for the diagnostic and the following outcome measures can be used for an objective inventory: 1. the Retropulsion test (problems with balance, gen- Timed Up and Go test
eral impression); The Timed Up and Go test is a short, practical test by 2. the Parkinson's Activity Scale (PAS) (functional which gait and balance are tested (TUG; see appendix 4.11).108 The TUG is a valid and reliable instrument for 3. the Timed Up and Go test (TUG) (functional mobil- patients with PD.109 It is important that the patient ity and balance); wears the same footwear during every measure- 4. the Six-minute walk test (physical capacity in the absence of freezing); 5. the Ten-meter walk test.
KNGF Guidelines for physical therapy in patients with Parkinson's disease B.6 Analysis
To round up the diagnostic process, the physical ther- apist answers the following questions: • Is physical therapy indicated? • Can the guidelines be applied to this individual 2. to preserve or improve physical capacity; 3. to prevent falling; Physical therapy is indicated if the patient: 4. to prevent pressure sores; 1. is limited in one or more activities (transfers, pos- 5. to stimulate insight into impairments in functions ture, reaching and grasping, balance and gait); and limitations in activities, especially in the area 2. has (or has the risk of) a decreased physical capac- of posture and movement.
ity caused by inactivity; 3. has an increased risk of falling or has fear to fall; If the patient is treated by another allied health disci- 4. has an increased chance of pressure sores; or pline, treatment will be attuned to this discipline. 5. has the need for information or advice on the dis- After formulation of the treatment goals, the physi- order, natural course and prognosis. cal therapist selects the appropriate interventions to achieve the formulated goals. These can be exercis- The patient is only eligible for physical therapy treat- ing functions or activities, but also giving informa- ment if there are no medical problems for which tion. Besides treatment goals and interventions, the therapy would be a contraindication, no personal or treatment plan includes the expected number of social factors that would influence compliance, and if treatment sessions needed, frequency of treatment the physical therapist assesses that the impairments sessions, and treatment location (at home, in the in functions and activities, as well as behavioral clinic, in a care facility). The starting point for the aspects, can be influenced by physical therapy. information plan is the need for information, advice If physical therapy is indicated and the guidelines and coaching which is identified during the diagnos- are applicable, the physical therapist, in consulta- tion with the patient, formulates, a treatment plan in which the individual treatment goals are included. If C Therapeutic
the physical therapist cannot confirm the indication for physical therapy he should contact the referring C.1 General
treatment
physician. It is possible that the physical therapist Location of the treatment
will advise a referral to another allied health disci- Physical therapy takes place in the primary health pline or to a medical specialist.
care practice, the patient's home, a rehabilitation center, a nursing home or a hospital. The choice of B.7 Treatment
location is determined by the objectives of treatment, After taking the medical history and performing but also depends on the abilities of the patient and physical examination, the physical therapist formu- the physical therapist, as well as on external fac- lates, in consultation with the patient, a treatment tors.12 Absorbing new information is often slower in plan. The treatment plan includes the physical thera- patients with PD, and the use of the acquired knowl- peutic treatment goals and prioritizes them. The main edge and skills in other circumstances is limited.91,116 treatment goal, the point of focus in the treatment Limitations in activities are often related to the plan, is in line with the patient's needs. In the for- home environment. Treatment focused on increasing mulation of the treatment goals and the main goal, activities preferably takes place at the patient's home. the motivation, ability and the understanding of the Improvement of the physical capacity preferably patient are taken into account. takes place in the physical therapist's practice (if there Possible treatment goals for patients with PD are: is room and equipment suitable for this purpose), at a 1. to increase safety and independence in the per- gym, or during the performance of recreational activi- formance of activities, with the emphasis on: KNGF Guidelines for physical therapy in patients with Parkinson's disease Based on the above the guideline development
with PD and decreases falls. Physical therapists teach group formulated the following recommendations:
patients to perform activities one after the other and consciously, using visual guidance if necessary.121,122 Improvement of activities (level 4)
The physical therapist gives the patient a simple The guideline development group takes the view that instruction before the performance of an activity or treatment of patients with PD focusing on improve- movement. During performance of an activity or ment of functional activities preferably takes place at movement no further instruction is given, as this will the patient's home.
lead to dual tasking. In therapy, optimization of one activity has to be fully completed before commencing Improvement of physical capacity (level 4)
optimization of the next activity. The guideline development group takes the view that improvement of the physical capacity of the Time of treatment
patient with PD preferably takes place in the physical It is important to take on- and off-periods into therapist's practice (if there is room and equipment account when planning treatment. Cognitive moving suitable for this purpose), at a gym, or during the per- strategies and cueing strategies are best used during formance of recreational activities.
the on-period, because at this time neurological prob- lems have less influence on the level of performance. Involvement of the caregiver
Also, physical capacity should be trained during these It is very important to involve the caregiver in the periods. Patients who are regularly off need cognitive treatment. Caregivers can assist in using cues and movement strategies especially during the off-periods. cognitive movement strategies when the patient has problems applying these strategies in daily life (e.g. Based on the above the guideline development
in case of a reduced cognitive function). The number group formulated the following recommendations:
of instructions should be limited, and the patient will benefit from only one instruction at a time, especially Exercising activities (level 4)
if he has cognitive impairments, for example in atten- The guideline development group takes the view that tion and memory. Caregivers do not have to fulfill exercising activities in patients with PD have to take the role of a therapist. However, they often are a key place in the on- as well as in the off- period. figure in the care of patients with PD, and patients with complex problems can only function in the Training of physical capacity (level 4)
home environment when a caregiver is present. It is The guideline development group takes the view that important to facilitate the patient's care by, for exam- it is advisable to train physical capacity (including ple, teaching lifting techniques to the caregiver when strength) in patients with PD during the on-period.
the patient with PD is confined to a wheelchair or bed, and by teaching how to assist the patient during Tempo of exercising
freezing and on/off-periods.
If impairments of cognitive functions are present, the physical therapist can only make limited use of C.1.3 Dual
cognitive movement strategies. Also, the amount of When performing two or more tasks at the same time advice given by the physical therapist will be limited. (dual tasking or multitasking), patients with PD find The physical therapist has to adjust tempo and dif- it difficult to pay full attention to all tasks. Mostly, ficulty of the therapy. Fatigue has a negative effect they need to pay specific attention when performing on the performance of activities. Therefore, in the ‘automatic movements' safely, such as walking. The case of fatigue, tempo and schedule of treatment (e.g. negative effect on gait and maintaining balance can spreading of the exercises during the day) need to be lead to unsafe situations, in daily life as well as during the treatment.46,117-120 Avoiding performance of dual tasks, during treatment as well as in daily life, increases the safety of patients KNGF Guidelines for physical therapy in patients with Parkinson's disease Recognizing a response fluctuation
err on the side of safety and choose an alternative A well-controlled medication regime is the responsi- form of therapy. bility of the primary care physician and the medical The Governmental Control warning concerns ultra specialist (mostly the neurologist, sometimes a geri- short wave therapy (not ultra sound therapy there- atric physician or rehabilitation physician). However, fore). However, it is advisable not to place an ultra- because of regular patient contact physical therapists sound over the stimulator, as the mechanical vibra- are able to recognize response fluctuations at an early tion may disturb the performance of the apparatus, stage. These fluctuations often arise when the disease and reflection of the vibrations on the stimulator or progresses or when medication is used over a long electrodes may cause heating of brain tissue by inter- time and can be partly corrected by an adjustment of medication. If the patient is experiencing response fluctuations they should contact their medical spe- Mental impairments, such as impairments in cogni- tion (e.g. poor memory, dementia and severe hal- Based on the above the guideline development
lucinations), personality and attention are relative group formulated the following recommendation:
contra-indications for the treatment of health prob- lems related to PD. These impairments influence the Recognizing response fluctuations(level 4)
patient's learning ability, making it difficult to pass The guideline development group takes the view that on information and give advice. In such cases the car- the physical therapist has a signaling function in egiver plays an even greater role in applying cognitive patients with PD.
movement and cueing strategies. If (unstable reaction The physical therapist has to draw the patient's atten- to) medication underlies these impairments, physical tion to response fluctuations.
therapy, physical therapeutic treatment or exercise can be postponed (in consultation with the referring physician) until the patient has adjusted well to the Deep brain stimulator
A deep brain stimulator forms an absolute contra- indication for diathermia (short waves or micro- waves). The high frequency electric current that is Freezing is a relative contra-indication for hydrother- caused by diathermia can reach the implanted system apy. In this case hydrotherapy is only possible with and in this way cause severe tissue damage (with individual supervision. severe consequences for the patient), or damage or disorganize parts of the implant (regardless if the Frequency and duration of the treatment
stimulator is on or off).123 Depending on the applied The duration and frequency of treatment sessions electrodes (coil or capacitor plates), its localization, and the course of treatment depends strongly on the the dose (continuous or pulsating), and the intensity requirements and potential of the patient, and on used, electromagnetic pulses may disorganize the the response to treatment. For each patient treatment stimulator, even if it is switched off. Furthermore, will focus on the main problem which is related to the implanted metals, including the electrodes, can the patient's requirements. If the patient has achieved concentrate the electromagnetic field, leading to the specified goals, or if the physical therapist does the body tissue in that area being heated, which can not expect changes (improvement, preservation or result in functional disorders and even necrosis. prevention of worsening) by physical therapy, treat- The Dutch Governmental Control on Public Health ment will be discontinued. Treatment will also be has published a serious warning about this (letter discontinued if the physical therapist expects that the 2001-14-IGZ). The Governmental Control states that patient is able to achieve treatment goals on his own implants must not be situated in the area treated. The (without therapeutic supervision). This is discussed safe distance of electrodes from the electromagnetic with the referring physician. An exercise period of fields has not been determined and it is advisable to at least four weeks is required to decrease limita- KNGF Guidelines for physical therapy in patients with Parkinson's disease tions in activities, and to improve the ADL.116,124-127 C.2.2 Cueing
During the first sessions it will become clear if using The performance of automatic and repetitive move- cues is advisable. A period of 8 weeks of exercise is ments is disturbed as a result of fundamental prob- required to improve the patient's physical capacity. lems of internal control. So-called cues are used to The patient can perform the exercises on his own at complete or replace this reduced or even absent inter- home, provided that he is well instructed. Also, the nal control. Cues are stimuli from the environment patient's safety has to be guaranteed. A low treatment or stimuli generated by the patient, which increase frequency (e.g. once a week to adjust the exercise pro- attention and facilitate (automatic) movements. It is gram) could be sufficient.
suggested that cues allow a movement to be directly controlled by the cortex, with little or no involve- Based on the above the guideline development
ment of basal ganglia. Not all patients benefit from group formulated the following recommendation:
using cues. Cues can be generated internally (bow, stretch, wave) or outside the body. Stimuli outside the Frequency and duration of the treatment (level 3)
body can be divided into moving stimuli (light of a There are indications that a period of at least four laser pen, a moving foot, a falling bunch of keys) and weeks is needed to decrease limitations in functional non-moving stimuli (sound of a metronome, stripes activities. To improve physical capacity, exercising on the floor, the grip of a walking-stick). for at least eight weeks is necessary, in which period With regard to therapeutic use of cues, a distinction is a low frequency of treatment (e.g. once a week to made between rhythmical recurring cues and one-off adjust the exercise program) is sufficient.
cues (see table 1). Rhythmical recurring cues are given Quality of the article found: C (Kamsma et al.116, as a continuous rhythmical stimulus, which can serve Comella et al.124, Dam et al.125, Patty126, Thaut et as a control mechanism for walking. The distance between (frequency of) rhythmical cues during walk- ing will be based on the number of steps needed to C.2 Treatment
perform the Ten-meter walk test at comfortable pace. If the patient's understanding, insight and memory One-off cues are used to keep balance, for example are sufficient, the physical therapist makes use of when performing transfers and for initiating ADL, or cognitive movement strategies and cueing strategies. when getting started again after a period of freezing.
Often the patient's learning ability becomes clear after a number of treatments. In this, feedback of the car- Types of cues
egiver is important. • auditory, for example stepping out on the third count to initiate a movement, or by use of a walk- C.2.1 Cognitive
movement
strategies
man, metronome, singing or counting (by patient The physical therapist can apply cognitive movement or caregiver) to continue walking;127-132 strategies to improvement transfers.91,116,121,128,129 In • visual, for example: stepping over one's foot, over cognitive movement strategies, complex (automatic) an object on the floor to initiate walking; follow- activities are transformed to a number of separate ele- ing somebody, stripes on the floor or projection ments which are executed in a defined sequence, and of a laser pen handled by the patient, or walk- which consist of relatively simple movement elements. ing with an inverted walking-stick by which the By doing this, complex movements are organized in patient has to step over the grip constantly to such a way that the activity is performed consciously. continue walking;128,129,133,134-138 Dual tasking during complex (automatic) activities in • using of a mirror;134 daily life is thereby avoided. Furthermore, the move- • focusing on an object (clock, painting) in the ment or (part of the) activity will be practiced and environment to improve posture; rehearsed in the mind. It is explicitly not intended • tactile, for example tapping on the hip or the that the activity or the movement will become auto- matic. Performance has to be consciously controlled • cognitive, for example focusing on the place the and can be guided by using cues for initiation.129 patient wants to go, and not on the doorpost, to KNGF Guidelines for physical therapy in patients with Parkinson's disease initiate walking; their daily activities, including transfers, by following • or a mental picture of the appropriate stride an exercise program that is focused on cues, as well as length to continue walking.
on cognitive movement strategies.129 C.3 Treatment
Based on the above, the guideline development
Depending on the findings in the diagnostic process group formulated the following recommendations:
(based on referral, history-taking and physical exami- nation), the treatment of patients with PD is focused The application of cognitive movement strategies
on one or more of the following treatment goals: improves the performance of transfers (level 2)
• stimulate safety and independence in the perform- It is plausible that in patients with PD the application ance of activities, with emphasis on: transfers; of cognitive movement strategies improves the per- posture, reaching and grasping, balance or gait; formance of transfers.
• preserve or improve physical capacity; Quality of the articles found: B (Kamsma et al.116, Nieuwboer et al.128). • prevention of pressure sores; • stimulate insight into impairments in functions The use of cues in combination with the applica-
and limitations in activities, especially of posture tion of cognitive movement strategies improves
and movement.
the performance of transfers (level 3)
There are indications that the use of cues in combi- During the therapeutic process goals are constantly nation with the application of cognitive movement evaluated and, if necessary, adjusted. In this, pro- strategies improves the performance of transfers in viding information and advice is a recurrent part. patients with PD.
Because of the progressive nature of the disease, pres- Quality of the article found: B (Müller et al.129). ervation and prevention of further decline can be a treatment goal.
Normalizing body posture
Goal: conscious normalization of body posture. Improvement of the performance of
Strategy: to exercise relaxed and coordinated move- transfers
ment, to provide feedback and advice.
Goal: to perform transfers (more) independently.
Strategy: to train transfers by applying cognitive There are indications (level 3) that axial rotation movement strategies and cues to initiate and con- while sitting and reaching (with preservation of bal- ance), and body posture, may be improved by an individual exercise program consisting of thirty ses- Two controlled studies (level B) demonstrate that cog- sions for ten weeks. This is based on a randomized nitive movement strategies can improve the perform- level B study.112 In this study, patients were taught to ance of transfers.26,128 For a detailed description of move in a more relaxed manner. Mobility as well as the applied cognitive movement strategies we refer to coordination improved by this approach.
the study of Kamsma et al., see appendix 5.116 Cues Eight principles underlay the exercise program, cover- improve the initiation of the transfer. The treatment ing seven phases – from easy (lying prone) to difficult in the study by Nieuwboer et al. consisted of 3 treat- (standing position): ment sessions of 30 minutes a week over 6 weeks. 1. (Conscious) use of proper muscles stimulates coor- The exercise program, that took place at the patient's home, was, among others, focused on using cues to 2. A wider joint mobility does not occur by stretch- improve gait and cognitive movement to improve the ing, but by relaxation. Relaxation is achieved by performance of transfers. The activities were trained moving slowly whilst maintaining quiet respira- under different circumstances.
tion using diaphragmatic breathing.
The study of Müller et al. (level B) demonstrated that 3. The emphasis lies on the axial structures (neck patients with PD can improve the performance of and back). Exercises to increase relaxation and KNGF Guidelines for physical therapy in patients with Parkinson's disease mobility of the extremities follow after exercising There are indications that in patients with PD, exercise the axial structures.
programs to improve coordination of muscle activity 4. Isolated efficient movements of the axial struc- make the performance of activities easier.
tures are easier to learn in a supported position, Quality of the article found: B (Stallibrass et al.139). where the patient can focus on the least number of segments possible.
The guideline development group takes the view that 5. When the patient becomes more competent in in patients with PD the change in posture towards performing the exercises, they can be made more complete flexion can often be corrected by conscious complex, either by decreasing support (from lying activity, by applying visual feedback (mirror) or ver- to standing) or by increasing the number of seg- bal feedback (also from the caregiver).141 To preserve ments that have to be coordinated. the effect the patient has to be working consciously 6. Each phase builds on the previous phase with on the correction of posture all the time. each session starting with rehearsing exercises from previous phases. Based on the above the guideline development
7. In each phase the exercises are functional, to group formulated the following recommendation:
make the transfer to daily activities easier.
8. Patients learn to perform the exercises independ- Change in posture towards flexion can often be
ently and consciously (cognitively), so they can corrected by applying feedback (level 4)
continue these at home (after treatment has end- The guideline development group takes the view that in patients with PD the change in posture towards flexion can often be corrected by applying feedback, In a randomized study, Stallibrass demonstrated (level either verbal or with the help of a mirror. B) the effectiveness of a twelve-week exercise pro- gram, focused on the coordination of muscle activity Stimulate reaching and grasping
whilst maintaining posture and movement.139 This Goal: to improve reaching and grasping, and manipu- exercise program was based on the Alexander tech- lation and movement of objects.
Strategy: to apply cueing strategies and cognitive The Alexander technique assumes that the impaired movement strategies, and to avoid dual tasking.
balance between head, neck and back cannot be restored by simply taking another, ‘better' posture, The exercise of reaching, grasping, and moving since in that way new tension patterns arise. The objects often takes place in cooperation with an physical therapist assesses changes in muscle activity, occupational therapist. Cueing strategies (to initiate balance (preserving body posture), and coordination and continue the activity) and cognitive movement by means of observation and palpation; next, he pro- strategies, and also avoidance of dual tasking are vides feedback on the changes which the patient tries important in improving the ability to reach, grasp to achieve by a learning and consciousness-raising and move objects.91 Patients learn to move in a more relaxed fashion and Based on the above the guideline development
to preserve their posture. The basic principles are group formulated the following recommendation:
taught on the basis of simple daily activities, such as sitting, gait and lying. Application of cueing strategies, cognitive move-
ment strategies and avoiding dual tasking (level
Based on the above the guideline development
4)
group formulated the following recommendation:
The guideline development group takes the view that in patients with PD reaching, grasping and moving Exercise programs to improve coordination of
objects is improved by applying cueing strategies, muscle activity make the performance of activi-
cognitive movement strategies and avoiding dual ties easier (level 3)
KNGF Guidelines for physical therapy in patients with Parkinson's disease Tremor usually becomes worse in the case of fear and c) exercises to strengthen the muscles of the or emotion and cannot be decreased by physical therapy. Relaxation (e.g. according to, Jacobson142, 2. tai chi (two group sessions a week for fifteen Schultz and Luthe143) or Halliwick (hydrotherapy)144 can decrease tremor. In patients suffering from freez- 3. referral to occupational therapy to identify and ing, hydrotherapy can take place only with individual alter any dangers present in the home environ- Based on the above the guideline development
It is plausible that these interventions are also effec- group formulated the following recommendations:
tive in patients with PD, especially in the early phase of the disease. If the strategies are applied in patients Relaxation methods (level 4)
with PD, the specific Parkinson's-related problems The guideline development group takes the view that have to be taken into account. in patients with PD tremor is decreased by relaxation Based on the above, the guideline development
group formulated the following recommendations:
Hydrotherapy (level 4)
The guideline development group takes the view that Exercises to improve balance (level 2)
in patients with PD hydrotherapy can take place only It is plausible that an exercise program consisting of with individual supervision.
exercising balance and training strength is effective in stimulating the balance in patients with PD.
C.3.4 Stimulate
Quality of the articles found: B (Hirsch et al.145, Toole Goal: to optimize balance during the performance of Strategy: exercises for balance and training strength.
Exercises to prevent falls (level 1)
It has been demonstrated that, in healthy elderly Hirsch et al.145 and Toole et al.146 demonstrated in persons, an exercise program focused on walking, their studies (level B) that an exercise program of ten mobility of the joints and muscle strength, and tai weeks (60 minutes, 3 times a week) exercising bal- chi decrease the number of falls.
ance and training strength is an effective treatment Quality of the article found: A1 (Gillespie et al.147) for problems with balance in patients with PD. The balance exercises consisted of pro- and retropulsion C.3.5 Improvement
tests, in which the patient learned to make use of Goal: to walk safely (and independently) and to visual and vestibular feedback, and of training the increase (comfortable) walking speed.
strength of the knee-flexors and knee-extensors and Strategy: to exercise walking with the use of cues and the muscles of the ankle at 60 percent of the maxi- cognitive movement strategies, to give instruction mum strength.
and to train muscle strength and mobility of the In the treatment of problems with balance in healthy elderly persons, three strategies proved to be effec- The studies of Lewis et al.138 and of Morris et al.45 (both level C), demonstrated that the use of rhythmic 1. walking outside three times a week, completed recurrent visual cues improves stride length and step with a home exercise program (30 minutes, 3 frequency in patients with PD.
times a week) with: a) walking variations (for- The studies of Thaut et al.127 and Behrman et al.148 ward, sideward, walking on toes, stepping over (both level B) and the studies of McIntosh et al.130, an object, walking while turning, and walking Howe et al.137 and Freeland et al.136 (all level C) dem- from sitting position); b) exercises to increase the onstrated that the use of rhythmic recurrent auditory mobility of, among others, neck, knees and hips cues improves walking speed, stride length and step KNGF Guidelines for physical therapy in patients with Parkinson's disease frequency in patients with PD.
Instructions to normalize gait can be effective. Three The study of Nieuwboer et al.128 (level B), demon- B-level studies who reported improvement of gait had strated that using visual and auditory cues, combined incorporated instructions to improve gait in the train- with instruction to improve foot take-off, stride ing involved.116,141,148 length and body posture, improves gait initiation and stride length in patients with PD.
Based on the above the guideline development
The study of Müller et al.129 (level B), demonstrated group formulated the following recommendations:
that an extensive (home) exercise program, focused, among others, on using cues, improves gait initiation Arm swing, wide base, heel contact (level 2)
and stride length in patients with PD.
There are indications that in patients with PD the It is currently unclear which patients benefit from instruction to exaggerate arm swing (training of the using cueing strategies and which patients do not.
trunk rotation), walk with a wide base, and good heel contact are effective in the improvement of gait Based on the above the guideline development
(walking speed or stride length) group formulated the following recommendation:
Quality of the articles found for arm swing: B (Behrman et al.148); for wide base: B (Formisano et Applying visual and auditory cues improves gait
al.141); for heel contact: B (Kamsma et al.116).
It is plausible that in patients with PD gait is improved Taking large steps (level 2)
by applying visual and auditory cues, which have It is plausible that training the patients with PD to been taught during active gait training.
take large steps is effective in the improvement of Quality of the articles found: B (Thaut et al.127, walking speed.
Behrman et al.148, Nieuwboer et al.128). Quality of the articles found: B (Behrman et al.148; Formisano et al.141).
Application of cues in combination with the
application of cognitive movement strategies
Standing upright, turning suddenly (level 4)
improves gait initiation and stride length (level 3)
The guideline development group takes the view There are indications that the application of cues that in patients with PD the following instructions in combination of cognitive movement strategies are effective in the improvement of gait: standing improves gait initiation and stride length.
upright (possibly with the use of a mirror for visual Quality of the article found: B (Muller et al.129) feedback); preventing sudden turns (and losing bal- ance), for which the instruction is: ‘Make a larger The physical therapist can give instructions which turning circle'. are focused on improvement of gait during training of all possible forms of walking, with variability in, Comfortable walking speed, stride length and trunk for example, walking direction, stopping, turning, rotation can improve through the use of a treadmill presence of obstacles, and terrain. In order to help the to exercise gait.149 A mirror placed in front of the patient remember the instructions, a lot of rehears- treadmill provides visual feedback about the body ing is needed; besides, the attention of the patient posture. If patients supports themselves with their has to be focused on one item only all the time. Each arms on the bars alongside the treadmill (as on a instruction causes in principle a dual task. Therefore, gangplank), by which the bodyweight is partly sup- it is important to assess for each patient whether the ported (preferably 20%), patients can walk faster and negative effect is not greater than the positive effect. make larger steps.149 The same effects on gait were The guideline development group advises relating found by de Goede et al., who used treadmill training the instruction to other movements, for example (in as part of their group treatment to improve gait and the case of increasing the arm swing) to swinging the arms in rhythm with the steps. KNGF Guidelines for physical therapy in patients with Parkinson's disease Based on the above the guideline development
Based on the above the guideline development
group formulated the following recommendation:
group formulated the following recommendation:
Treadmill (level 2)
It is plausible that in patients with PD (up to H&Y Use of prompts (level 4)
III), gait exercises on a treadmill increase comfortable The guideline development group takes the view that walking speed and stride length. Quality of the article in patients with PD the use of prompts makes the start found: B (de Goede et al.150, Miyai et al.149).
of movements easier after freezing. Cognitive movement strategies can be used after a A randomized study (level B) demonstrated that motor block or a period of freezing. Before stepping a strength training program of 16 sessions for 8 out, the patient can first sway from one leg to the weeks, consisting of resistance training (60% maxi- other, supported by counting or by the order: ‘One, mum strength, 12 repetitions) with the emphasis on two and walk…,' to facilitate initiation of walking.
lower extremities and muscles of the abdomen, is an effective tool to improve stride length and walking Based on the above the guideline development
group formulated the following recommendation:
Based on the above the guideline development
Application of cognitive movement strategies to
group formulated the following recommendations:
stimulate the onset of walking (level 4)
The guideline development group takes the view that Training of muscle strength (level 3)
in patients with PD the following cognitive move- There are indications that gait in patients with ment strategies stimulate the onset of walking: stand PD improves by training the strength of the lower upright; bring the weight on the heels; transfer the weight to one leg; step out with the other leg, make a Quality of the article found: B (Scandalis et al.151).
large step, and keep on walking.
Training of trunk mobility (level 4)
Freezing can be prevented in part by making use of The guideline development group takes the view that rhythmic recurring cues and by keeping instructions gait in patients with PD improves by increasing or pre- to a minimum.
serving trunk mobility.
To make the start of movements easier (after freez- ing), use can be made of: Prevention of inactivity and maintenance
• flexing and extending the knees; or improvement of physical capacity
• transferring the weight from the left to the right Goal: maintenance or improvement of physical foot and back, possibly with swaying back and forth a few times; Strategy: providing information on the importance • suddenly swinging the arms in front (‘pointing of exercising or playing sports, training of aerobic capacity, muscle strength (with the emphasis on the • first make a step backwards, and then forwards; muscles of the trunk and legs), joint mobility (among • first stand upright, than stretch, have a short others, axial) and muscle length (among others, mus- moment of conscious relaxation and correction of cles of the calf and hamstrings).
posture before initiating the movement again; • raising the non-weight-bearing leg and stepping out making a substantial first step; ‘PD, moving and health' (in Dutch) provides informa- one-off cues. tion for patients with PD.152 Patients are encouraged to continue, or return to playing sports.53 Patients are encouraged to strive for the ‘Dutch Standard of Healthy Moving'.104 Depending on the problems present, exercise is increased and more pleasurable KNGF Guidelines for physical therapy in patients with Parkinson's disease when taking place in a group. These groups can be Training aerobic capacity
specific exercise groups for patients with PD (e.g. Two level C studies (Reuter et al.157, Baatile et al.158) swimming and gymnastics), or exercise groups for the showed that exercise programs focused on improving elderly in general (see appendix 2).
aerobic capacity also improve motor skills.
One level B study (Bergen et al.159), demonstrated Based on the above the guideline development
that an exercise program, which is focused on group formulated the following recommendation:
improvement of aerobic capacity, can also improve the aerobic capacity of patients with PD in the early Providing information (level 4)
The guideline development group takes the view that providing information on (increasing) exercise or Based on the above the guideline development
playing sports to patients with PD immediately after group formulated the following recommendation:
the diagnosis, has a preventive effect on deterioration of the physical capacity of these patients.
Improvement of joint mobility (level 2)
It is plausible that an exercise program focused on the Training joint mobility
improvement of joint mobility combined with activ- Level B studies showed that exercise programs ity related (e.g. gait or balance) exercises improves ADL focused on improving joint mobility, combined with training of gait and balance, improve motor skills Quality of the articles found: B (Comella et al.124, (Comella et al.124, Patti et al.126, Pachetti et al.153, Marchese et al.134, Patti126, Formisano et al.141, Marchese et al.134), ADL (Comella et al.124, Patti et Palmer et al.154, Pachetti et al.153) al.126, Formisano141, Palmer et al.154, Pachetti et al.153 and mental functioning (Comella et al.124, Patti et Improvement of muscle strength (level 2)
al.126). One level B study (Hurwitz155) showed that an It is plausible that in PD a program focused on the exercise program focused on improving joint mobil- improvement of muscle strength increases muscle ity, in combination with improving mobility and self- care, improved memory, among others. Furthermore, Quality of the articles found: B (Bridgewater et al.156, one level B study (Schenkman et al.112) showed Hirsch et al.145, and Toole et al.146) and C (Reuter et that an exercise program focused at improving joint al.157, Scandalis et al.151).
mobility and coordinated moving incorporated in ADL improves functional axial rotation and reach (bal- Improvement of aerobic capacity (level 3)
There are indications that an exercise program focused on the improvement of aerobic capacity Training of strength
improves motor skills.
Three level B studies (Bridgewater et al.156, Hirsch Quality of the articles found: C (Reuter et al.157, et al.145 and Toole et al.146) and two level C stud- Baatile et al.158).
ies (Reuter et al.157, Scandalis et al.151), showed that exercise programs which are, among others, focused Training physical capacity (level 4)
on improving muscle strength (of the lower extremi- The guideline development group takes the view that ties and trunk), may also improve muscle strength in the exercise program needs to be formulated for each patients with PD (in the early to middle phase). In patient, in line with the patient's physical problems the study of Scandalis et al.151 Sixteen sessions were delivered during a period of eight weeks. In the study of Toole et al.146, strength was trained at 60% of max- For patients with osteoporosis the KNGF-guidelines imum strength resistance, with up to 12 repetitions of ‘Osteoporosis' have to be followed.
the exercises based on the muscle strain.
Preserving the physical capacity preferably takes place during those times of the day when the patient is functioning well (e.g. during on-periods), as only KNGF Guidelines for physical therapy in patients with Parkinson's disease then the patient is able to exercise optimally. Patients C.3.8 Falls
prevention
are offered an exercise program with fitness equip- Goal: reduce and/or or prevent falls. ment (including a home trainer, if necessary with Strategy: list possible causes of falls with a falls diary; low resistance) and a treadmill. Furthermore, infor- providing information and advice, improvement mation is provided on (increasing) exercises and of body posture, strength training, improvement of playing sports, at home as well as in exercise groups coordination and balance, concentrating on the cause (Parkinson's specific or elderly in general). The physi- of the problems such as maintaining balance and cal therapist can facilitate the exercise program at increased falls risk; reduce the fear to fall (possibly home. A diary serves as an evaluation instrument with the use of hip protectors). (see appendix 4.14). Aids, such as a walking stick, To gain insight into the frequency of falling, the poles (Nordic Walking), a rollator or a bicycle with an circumstances in which falls take place and the pos- electric aid engine can support this. Providing infor- sible causes of falls, the guideline development group mation on the aids themselves and supporting the advises patients together with their caregivers, to fill application for the aids falls inside the scope of the in a falls diary (see appendix 4.3).59,91,120,162 To prevent falls, the physical therapist should provide balance training and inform the patient about aids, Prevention of pressure sores
the role of the occupational therapist and about the Goal: prevention of pressure sores.
side-effects of medication which can be related to Strategy: giving advice and (in)active exercising to falling, such as orthostatic hypotension. Fear to fall stimulate good posture in bed or in a wheelchair (pos- plays an indirect role in falling. Therefore, part of the sibly in consultation with an occupational therapist) physical therapeutic treatment of patients with PD is and cardiovascular functioning, and to prevent con- to decrease this fear.
See paragraph C.3.2 for the treatment of poor body posture and insufficient trunk mobility as causes for Although most interventions to prevent pressure falling. If freezing is the cause of falling: see para- sores are performed by nurses, the physical therapist graph C.3.5.
is actively involved in taking measures to prevent pressure sores.160,161 The occupational therapist pro- vides advice on support while sitting and lying, and The guideline development group takes the view on aids, especially for static activities (e.g. a hand that it is advisable to refer the patient to courses for splint and a tray on a wheelchair). Furthermore falls prevention, which aim at improving strength, the expertise of the occupational therapist is used balance (preserving the body posture) and coordina- in the selection of pressure relieving products such tion (see appendix 2). In the case of patients with as pillows, and the adjustment of wheelchairs and an increased falls risk KNGF-guidelines ‘Osteoporosis' beds. For possible advice on nutrition, the patient is should be consulted. See paragraph C.3.4 for the referred to a dietitian.
physical therapeutic training of balance.
Physical technical applications
Based on the above the guideline development
There is insufficient evidence that the use of physical group formulated the following recommendation:
technical applications (e.g. ultrasound, UKG, infra- red or ultraviolet light and laser) are effective in the Fall incidents (level 4)
treatment of pressure sores. Extensive information The guideline development group takes the view that on treatment and prevention of pressure sores can be it is advisable to refer patients with PD to a course for found in the ‘NHG Standard (M70) decubitus' (http:// falls prevention in the early stage of the disease. nhg.artsennet.nl) and the ‘CBO Guidelines Decubitus There is insufficient evidence that falls training (train- ing of falling or techniques of falling) is an effective means to reduce the fear of fall or the falls risk. Based KNGF Guidelines for physical therapy in patients with Parkinson's disease on the fundamentally disturbed posture and balance Based on the above the guideline development
reactions, the guideline development group expects group formulated the following recommendation:
no effect of such training. The guideline development group even takes the view that such training might Orthostatic hypotension (level 4)
have negative effects. The guideline development group takes the view that Patients are often bothered by wearing shoes with in patients with PD, information and advice on ortho- smooth soles, rubber soles (‘stick' to the floor) or high static hypotension can help to prevent fall incidents, heels.84 In this case the physical therapist can pro- which are a consequence of hypotension. vide information about this to the patient. Fear to fall
Based on the above the guideline development
Fear to fall might lead to inactivity and is further group formulated the following recommendation:
associated with an increased falls risk. At the moment it is unclear how the physical therapist can decrease Footwear (level 4)
the fear to fall. A reduction in fear to fall may occur The guideline development group takes the view that if the patient is taught how to stand up from a sitting in patients with PD information and advice on foot- position on the floor.
wear may decrease the number of falls.
Based on the above the guideline development
Occupational therapy might prevent falling in the group formulated the following recommendation:
elderly.147 Although extrinsic factors (e.g. doorsteps and insufficient lightning) play a much smaller role Standing up after a fall (level 4)
than intrinsic factors in falling, an inventory of the The guideline development group takes the view that dangers in the daily life situation, in combination by teaching patients with PD how to stand up from a with adjustments to the home, can be advisable to sitting position on the floor, the fear to fall decreases prevent falling.
in these patients.
The physical therapist takes responsibility (if neces- sary together with the occupational therapist) for the C.3.9 Aids
application of, and the training in the use of the dif- In case of patients with PD the use of aids can be ferent (walking) aids (see table 2). They also provide advisable. The physical therapist can provide the information on who is responsible for the mainte- patient with proper information and refer to an occu- nance and repair of the aids. See paragraph C.3.9 for pational therapist in time to identify possible adapta- a more detailed discussion of the possible aids.
tions in the home environment (see table 8).
Orthostatic hypotension can be a side-effect of medi- cation (levopoda, selegeline and dopamine agonists). Walking aids, such as a walking-stick and rollator, This causes a partial or complete syncope, not only can increase the independence and safety of patients occurring during standing up or after exertion, but with PD. However, at the same time they can make also when the patient is standing for a long time. walking more complex and more difficult, as by using Patients with PD can be given the same advice as the these aids the performance of a dual task is required. elderly persons with orthostatic hypotension in gen- Furthermore, inadequate use of, for example, a rolla- tor, can worsen the posture. Patients suffering from • while standing, activate the muscles of the freezing benefit more from a rollator with so-called leg163,164, look out for instability of the posture; compression brakes which are activated when a • hold one leg higher (on a ‘platform') in case of a patient leans on the rollator. Cubo advised against feeling of dizziness;165 a walking frame for patients who suffer from freez- • provide information on avoiding to get up quick- ing.166 In case of severe difficulty in maintaining ly, to stand still for a long time, and to lie flat (in balance, a wheelchair should be advised, because of the daytime) for a long time.163 co-morbidity related to a high risk of falls. KNGF Guidelines for physical therapy in patients with Parkinson's disease Based on the above the guideline development
are worn at the right moment.
group formulated the following recommendations:
Based on the above the guideline development
Walking aids (level 4)
group formulated the following recommendation:
The guideline development group takes the view that providing information and advice on (walking) aids Hip protectors (level 1)
to patients with PD, and training patients in the (tem- It has been demonstrated that, in an elderly, high-risk porary) use of these aids, decreases the incidence of population living in institutional care, hip protectors falls in these patients.
prevent hip fractures due to falls, when the hip pro- tectors are worn at the right moment.
Walking frame (level 3)
Quality of the articles found: A1 (Parker and There are indications that in patients with PD the use Gillespie167); A2 (Schoor et al.168).
of a walking frame has to be advised against in case of C.4 Information
Quality of the article found: B (Cubo et al.166). During the diagnostic process, the need for informa- tion and advice is identified. Based on this, the physi- In comparison to ‘healthy' elderly, patients with cal therapist formulates an individual information PD sustain more fractures of the hip (see paragraph plan. Information is possible from the moment that A.12.3). It has been demonstrated in the healthy the diagnosis is made. Bodenheimer et al. distinguish elderly (level 1) that hip protectors (a kind of forti- two forms of information and advice in chronic fied underpants) are effective in reducing hip frac- patients: the traditional information and the infor- tures due to falls.167 A problem when prescribing hip mation to stimulate self-management.169 Providing protectors is, however, that they are often not worn disease specific information is part of the traditional (at the right moments, for example at night) which information, for example: 1) information on the makes them less effective.168 In patients who have syndrome; 2) the importance of the hour medication recurrent falls a nurse can give advice when purchas- should be taken; 3) the importance of compliance ing them. In the healthy elderly, it has been demon- with therapy; 4) the objective of the therapy; 5) the strated (level 1) that hip protectors prevent hip frac- use of aids; 6) the importance to keep on exercising tures through fall incidents, when the hip protectors and, if possible, to play sports; 7) information on Table 8. Core areas for aids in Parkinson's disease Core area
Aids or adjustments
• walking aid (e.g. rollator) Transfers or changing body position • raised toilet • aids that facilitate getting in or out of bed (such as high-low bed, patient lift, sliding board, handles on the sides of the bed) • walking aid (i.e. rollator) • other aids that increase the mobility (such as wheelchair, scoot Falling and increased falls risk • walking aid (i.e. rollator) • shoes with sufficient support and soles with sufficient grip KNGF Guidelines for physical therapy in patients with Parkinson's disease the Dutch PD Association; 8) information on the role of the caregiver. Skills enabling the patient to react 2. social norms (e.g.: How do others perceive the adequately to (new) problems are part of the infor- change in behavior?) and mation stimulating self-management. Patients learn 3. self-efficacy, the extent to which one considers to deal with the progressing problems and by doing himself capable of showing a behavior or not.
so gain confidence in their own capabilities. Central to this are the action plans made by the patient, in The step-by-step model in relation to information whom the patient sets goals that can be achieved in consists of six steps: 1) being open; 2) understanding; the short term. For example: the next two weeks I'm 3) wanting; 4) being able; 5) doing; and 6) keep on going to walk outside for half an hour every Monday, doing. The final step can only be taken if the preced- Wednesday and Friday afternoon. To assess the feasi- ing steps have been taken. bility of a goal, patients can be asked to indicate on When treatment takes place within a team, it is very a scale from zero to ten how certain that goal will be important that all the members of that team work achieved. Experience shows that a score of seven or according to the same method and are informed higher is sufficient for a feasible goal.169 about each other's steps. When mental impairments are present (e.g. impair- ments in attention and memory) it is important to C.6 Compliance
discuss only one subject at a time and to keep the At least one out of three patients has problems with information or advice short. In providing informa- exercising at home or with holding on to advice pro- tion and advice, existing information material, such vided.173 The three most important factors that ham- as brochures and video's can be used. These can be per compliance with therapy are: obtained from the Parkinson's Patient Society and the 1. the problems that patients experience in following the instructions of the physical therapist; The physical therapist makes a plan and evaluates to 2. the lack of positive feedback; what extent the goal is achieved (according to the 3. a feeling of helplessness (e.g.: It won't help me).
module Methodical Conduct of Physical Therapy Diagnosis and Intervention). With respect to informa- A number of measures can be taken to increase com- tion and advice, the physical therapist asks himself: pliance with therapy.173 A good relation between Does the patient know what he ought to know and is physical therapist and patient is essential. The patient he doing what he should be doing? must have the feeling that he is listened to and understood. The guideline development group dis- C.5 Change
tinguishes between compliance with therapy during In treatment of patients with PD, behavioral change the treatment period (short term) and the compliance has an important place in decreasing inactivity, pre- after treatment period (long term).
venting fall incidents, and increasing the potential to treat these patients. Supplying information is central Compliance with therapy in the short
to behavioral changes. The model of Van der Burgt and Verhulst serves as a starting point in supplying Behavioral change plays an important role in encour- information to patients in allied health.170 aging compliance with therapy in the short term, Van der Burgt and Verhulst integrated the ASE- applying methods such as reminders and positive model for determinants of behavior (Attitude, Social feedback. These methods link the desired behavior Influence and Personal Efficacy)171 and the step-by- (e.g. the performance of exercises) to daily routines, step educational model proposed by Hoenen et al.172 as a result of which the new behavior might become a According to the ASE-model, the most important routine. The physical therapist teaches the patient to determinant of behavior is the patient's intention to use reminders, for example by instructing the patient show that behavior. The intention to change behav- to perform a certain exercise always after the eight ior is influenced by: o'clock news. If mental impairments hamper the use 1. the attitude of a person with respect to a certain of reminders, the caregiver assists in performing the KNGF Guidelines for physical therapy in patients with Parkinson's disease desired behavior (see paragraph C.1.2). The positive strive for this practical application, it has to be clear consequences of (compliance to) therapy are empha- that this can be a bottleneck too (see paragraph C.1). sized by giving positive feedback.
The patient benefits from good cooperation between the physical therapist and the (referring) physician Compliance with therapy in the long
and the report and support of each other's advice. The same goes for the cooperation of members of a To increase compliance with therapy, the feeling of multidisciplinary team. self-efficacy, perception of the complaint and behav- ioral abilities of the patient are of importance. For Specific physical therapy techniques
compliance with therapy in the long term, confi- No studies are available which demonstrate that cryo- dence in one's own capabilities (the feeling of self- therapy, thermal therapy, massage, and manipula- efficacy) is essential. Goals have to be achievable for tive techniques are effective for decreasing problems the physical therapist and the patient (see paragraph C.4). Also, giving positive feedback on the goals With respect to the treatment of co-morbidity (for achieved (or parts of it) plays a role.
example typical problems in the elderly such as Particularly in patients with PD it is very important arthritis) the guideline development group refers to to strive for a new goal only when the previous goal the guidelines concerned.
has been achieved. Therefore, working step-by-step is essential and has to be taken into account when Based on the above the guideline development
trying to achieve a change in behavior. If the car- group formulated the following recommendation:
egiver is involved in the treatment, care should be taken to ensure that they do not overload the patient Specific physical therapy techniques (level 4)
with information. This goes for the instructions dur- The workgroup takes the view that cryotherapy, ther- ing exercising as well as for giving information and mal therapy, massage, and manipulative techniques should not be used in patients with PD.
During and after therapy, emphasis is put on what has been achieved. That which has not (yet) been achieved is used to provide information about what The physical therapist evaluates the treatment out- is difficult for the patient or what the problems are. come regularly and systematically by comparing it to Also non-compliance with therapy needs to be a sub- the treatment objectives. On the basis of this, adjust- ject of discussion - try to discover the cause and look ment of the treatment plan can take place. In the for alternatives. The patient's perception of a com- case of complications during treatment, the patient plaint determines the future actions of the patient can be referred back to the physician. The frequency and must therefore be clarified. of evaluation depends on the objective of treatment. On the one hand this is done by asking patients what The application of techniques to improve postural or they think about their complaints and if they think movement behavior is evaluated frequently (at the they will return. If necessary, the physical thera- start of each following session). The evaluation of the pist adjusts this perception by giving information. physical capacity, on the other hand, can only take Alternatively this is done by asking patients what place after a longer period. To evaluate the outcome they have already tried to do themselves to reduce of treatment the same outcome measures that were the problems. Also, the patient's behavioral abilities used during history-taking and physical examination determine how problems arising in the future will be dealt with. To increase patients' behavioral abilities, Central to the evaluation is measuring the effect of they patients need to learn how they can apply their treatment on the patient's daily functioning. The knowledge to future situations, for example by sup- functional status of the patient is determined based plying information on the working mechanism and on changes on the Patient Specific Complaints ques- best application of cueing strategies and cognitive tionnaire. The guideline development group takes movement strategies. Although the therapist should the view that in addition to the Patient Specific KNGF Guidelines for physical therapy in patients with Parkinson's disease Complaints questionnaire, measurement of the Final evaluation, conclusion and reporting
‘Global Perceived Effect' should also be used (see When treatment goals have been achieved, or when appendix 4.12).
the physical therapist takes the view that physical therapy has no longer an additional value, the treat- Based on the above the guideline development
ment will be discontinued.
group formulated the following recommendation:
The treatment will also be discontinued if the physi- cal therapist expects the patients to be able to achieve Evaluation (level 4)
the treatment goals on their own (without thera- The guideline development group takes the view that peutic supervision). At discharge, but preferably also the treatment of patients with PD should be evaluated during the treatment period, the physical therapist with the Patient Specific Complaints questionnaire should inform the referring physician about, among (PSK) and measurement of ‘Global Perceived Effect'.
other things, the (individually determined) treatment goals, the treatment process and the treatment out- come. The Dutch Institute of Allied Health Care (NPi) Preservation of improved activities in daily life
has developed a manual for reporting by order of, and Strategies to stimulate ADL are sometimes effective for in close cooperation with, the Royal Dutch Society a short period of time only. Introducing permanent for Physical Therapy (KNGF), the Dutch College of cues (to initiate as well as to continue the movement) General Practitioners (NHG), and the Dutch Society in the home environment can be an aid to retaining of Exercise Therapists according to the methods of the effects of treatment outcome for a longer period Mensendieck and Cesar (VvOCM).93 With this manual, of time. It is important to evaluate the patient after a agreements can easily be made on the time frame in certain period of time. which the physical therapist reports to the referring Because of the progressive nature of PD, it is important physician, the content of this report and situations for patients to stay active. Effects of physical activity in which reporting should take place. This manual is aimed at improving bone mass become visible only also used for reporting between physical therapists after a year (see the KNGF-guidelines ‘Osteoporosis'). in primary and secondary health care. The manual Therefore, the physical therapist encourages the can be accessed online on the HOF-site of the NPi: patient to keep on exercising after the treatment peri- http://www.paramedisch.org/hof/. Reporting occurs od has ended. The patient may keep a diary in which according to the KNGF-guidelines ‘Physical therapy the frequency and extent of exertion is noted (see documentation and reporting' (revised version).175 appendix 4.14), in order to increase the possibility that Besides the minimally required data it is advisable to the patient will continue the active lifestyle. The Borg mention in the final report: scale is used to quantify the feeling of exertion (see • if the patient has been treated according to the appendix 4.13). The Borg scale is a valid measurement instrument to determine the exertion intensity, show- • on which points and why the treatment deviated ing good correlations with physiological criteria.174 from the guidelines; and • if appointments are made for a check-up. An appointment for a check-up can be made to Legal status of the guidelines
assess how well the effects of treatment have been These guidelines are not statutory regulations. They retained and if any new problems have developed. provide knowledge and make recommendations If necessary, therapy can be continued immediately based on the results of scientific research, which after check-up. It is possible for patients to receive a healthcare workers must take fully into account if prolonged period of treatment. It is the task of the high-quality care is to be provided.175 Since the rec- physical therapist to assess whether treatment is ommendations mainly refer to the average patient, appropriate and to remain alert to the possibility that healthcare workers must use their professional judg- the patient could become dependent on the physical ment to decide when to deviate from the guidelines if that is required in a particular patient's situation. KNGF Guidelines for physical therapy in patients with Parkinson's disease Whenever there is a deviation from recommenda- Royal Dutch Society for Physical Therapy, and the tions in the guidelines, this must be justified and Dutch Society for Mensendieck and Cesar Exercise Therapy (VvOCM) funded the development of the practice recommendations. Revisions of the guidelines
None of these had a role in the preparation of this The method for developing and implementing guide- review or the decision to submit this review for pub- lines states that all guidelines should be revised with- in a maximum of three to five years after the original publication.1,2,8 This means that the KNGFtogether Practice Recommendations Development Group
with the guideline development group, will decide B.R. Bloem PhD (neurologist, RUNMC), C.J.T. de Goede whether these guidelines are still accurate in 2007, MSc (physical therapist, human movement scientist, but at the latest in 2009. If necessary, a new guide- VU University Medical Center), Mrs. M. van Haaren line development group will be set up to revise the (physical therapist, Rehabilitation Centre Breda), guidelines. The current guidelines will no longer be H.J.M. Hendriks PhD (physical therapist, health valid if there are new developments that necessitate a scientist, clinical epidemiologist, Dutch Institute of Allied Health Care, Centre for Evidence Based Physiotherapy), Mrs. M. Jaspers (Mensendieck exer- F External
cise therapist, Fysio Ludinge), Y.P.T. Kamsma PhD The production of these guidelines is financially sup- (physical therapist, human movement scientist, ported by the Parkinson's Patient Society and the Center for Human Movement Sciences), Mrs. S.H.J. Dutch Institute of Allied Health Care (NPi). Possible Keus MSc (physical therapist, human movement sci- interests of the subsidizing bodies have not influ- entist, LUMC), M. Munneke PhD (physical therapist, enced the content of the guidelines nor the resulting human movement scientist, clinical epidemiologist, RUNMC), Mrs. J. Westra (physical therapist, Nursing home Maartenshof), B.Y. de Wolff MSc (Cesar exercise therapist, Medical Center De Vecht).
For the development of these KNGF-guidelines special words of gratitude are in order for the members of Review Panel (expert professionals)
the Steering Committee, the members of the Practice Mrs. A. Coerts (speech therapist, Spaarne Hospital), Recommendations Development Group, the members Mrs. Y. van den Elzen-Pijnenburg, occupational of the Review Panel (expert professionals), all physi- therapist, RUNMC), A.N. Goudswaard PhD (general cal therapists participated in the field check and the practitioner, Dutch College of General Practitioners), patient panel. This study was funded by the Dutch J.J. van Hilten PhD (neurologist, LUMC), Mrs. D. Jones Parkinson's Disease Association (Parkinson Patiënten PhD (physical therapist, Northumbria University, Vereniging) and Dutch National Institute of Allied UK), R. Koopmans PhD (nursing home physician, Health Professions (NPi).
RUNMC), G. Kuijpers MD (rehabilitation physician, Rehabilitation Centre Breda), G. Kwakkel PhD Steering Committee for guarding the development
(physical therapist, human movement scientist, VU process:
University Medical Centre), Mrs. A. Nieuwboer PhD M. Heldoorn, PhD and A.L.V. Verhoeven (Royal (physical therapist, Catholic University Leuven, Dutch Society for Physical Therapy, KNGF); E. de Jong Belgium), Mrs. L. Rochester PhD (physical therapist, and M. van Gennep (Dutch Society for Physical Northumbria University, UK), K.P.M. van Spaendonck Therapy in Geriatrics), Mrs. J. van Sonsbeek, MSc PhD (neuro-psychologist, RUNMC), Mrs. M.M. Samson (Dutch Society for Mensendieck Exercise Therapy, PhD (geriatrician, UMC Utrecht), J.D. Speelman PhD NVOM), Mrs. H. Verburg (Cesar Kinesiology Society, (neurologist, AMC), F. Vreeling PhD (neurologist, VBC) and P. Hoogendoorn, MSc (Dutch Parkinson's Maastricht University), Mrs. S. Vernooy and Mrs. C. Disease Association). The Dutch Parkinson's Disease van der Bruggen-De Vries (Cesar exercise therapists, Association (Parkinson Patiënten Vereniging), the Scheper Hospital).
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KNGF Guidelines for physical therapy in patients with Parkinson's disease Overview of abbreviations and concepts used in the guidelines
Akinesia:
Difficulty with starting a movement, especially during the off-periods.
Balance:
The overall term for a number of functions, among which postural and balance reactions, vestibular functions, coordinative functions (control over and coordi- nation of conscious movements), and proprioceptive functions, which together determine if a person is able to keep his balance (sufficiently).
N.B. In the ICF the term ‘balance' is only used with regard to vestibular functions.
Delayed performance of voluntary movements.
Cognitive movement
Conscious performance of actions in which complex (automatic) activities are strategies:
transformed to a number of separate elements that have to be executed in a set order, and which consist of relatively simple movement components. Physical capacity:
The overall term for the ICF-terms: • exercise tolerance functions such as aerobic capacity; • mobility of joints; Cueing strategies:
Usage of stimuli, whether or not consciously (but with attention), in the environ- ment or aroused by the patient to facilitate moving.
Dual tasking:
Performing several motor or cognitive tasks simultaneously.
Dyskinesia:
Abnormal, involuntary movements during the on period, often becoming more intense during activities. Side effect of long-term usage of medication, especially levodopa.
Fatigue:
An overwhelming feeling of tiredness, exhaustion or lack of energy, which may occur as a consequence of depression, sleeping problems, or akinesia. Walking accelerated with quick, short, shuffling steps. Increases with the duration of the disease. Festination is strongly associated with freezing and falling.4 Freezing:
Temporary, involuntary inability to move, especially during the off periods. Mostly, the episodes of freezing are short (< 10 seconds), and of a temporary nature. Sometimes, a complete akinesia occurs, but mostly freezing manifests itself in trembling legs.1 Freezing can be preceded by festination and might lead to falls Freezing occurs especially in case of starting, turning, and when approaching a destination, a small doorway or obstacle(s).1,2 Stress, deprivation of sleep, fear, and emotional excitement can enhance freezing. Freezing occurs especially after a long term treatment with levodopa and in an advanced stage of the disease.3 After a disease period of five years freezing can be found in more than 50 percent of the KNGF Guidelines for physical therapy in patients with Parkinson's disease Lack of activities, which expresses itself, among others, in: 1) loss of automatic movements, 2) decreased movement of the arm(s), 3) masked face. Idiopathic:
With unknown cause.
Incidence:
The number of new cases of a certain disease in a community during a defined period (e.g. a year). Smallness of handwriting.
Mobility:
Moving by changing body position or location, going from one place to another, carrying, moving and manipulating objects, walking, running or climbing, and moving by using different forms of transportation.5 N.B. Contrary to the ICF, this term is not used with regard to the mobility of joints or bones.
Dutch Standard of
A moderately intensive physical activity for half an hour at least five days, but Healthy Moving:
preferably every day of the week.6 Thirty minutes continuously is not needed; it can also be three blocks of ten minutes. The minimal duration is five minutes con- tinuously. Examples for moderately intensive physical activity for adults are: walk- ing at a speed of 5 to 6 km/hour and cycling at a speed of 15 km/hour. For people over 55 years of age, for example, a walking speed of 3 to 4 km/hour and cycling speed of 10 km/hour is acceptable. However, for non-active people, with or with- out limitations, all extra physical activity is welcome.
Urinating frequently at night.
Fluctuations in mobility as a consequence of the effectiveness of the medication. During the off period the medication is taken, but not effective. When the medica- tion is effective, it is called the on period.
Predictable and unpredictable fluctuations in the mobility as a consequence of the good (on) or poor (off) response to the use of levopoda. Arises by a long-term use of levodopa. During the on period the patient might suffer from dyskinesias.
Orthostatic
A decrease in blood pressure in case of quick changes of the body posture (e.g. transfer from sitting to standing position). The symptoms are dizziness, everything going black, fainting, tachycardia and headache. Prevalence:
Number of cases of a disease that is present in a community at a certain time.
Prognostic factors:
Factors that are related to continuation of the complaints. These factors can either have a favourable effect on the course of the complaints or an unfavourable effect, which might lead to an increase or continuation of the complaints.
Propulsion:
Tendency to fall forward.
KNGF Guidelines for physical therapy in patients with Parkinson's disease Response fluctuations: Fluctuations in the effectiveness of medication which occur frequently when the
disease progresses and by long term usage of medication (e.g. wearing off, on/off- problems, dyskinesias, freezing).
Tendency to fall backwards.
Rigidity:
Stiffness of the muscles, characterized by the cog-wheel phenomenon, in which the muscles lengthen jerkily during passive extension.
Rest tremor:
Rhythmic (alternating) trembling, often of the hands. Especially present in rest and giving the impression of counting money or pill rolling. Disappears or decreases by intended movements, is absent during sleep and is aggravated by emotion or attention. Intensity may change (spontaneously). Muscle strength:
Functions which are related to the strength developed by the contraction of the muscle or muscle groups.5 Syncope:
A sudden unconsciousness that can last a few seconds to several hours, sometimes preceded by dizziness, perspiration and nausea. This unconsciousness can be caused by hypoxia of the brain, a sudden change in blood composition or brain Transfer:
Move oneself from one surface to another (e.g. turning in bed).5 Urge incontinence:
Being insufficiently able to hold one's water in case of micturation urge and there- fore passing urine (often on the way to the toilet). The tendency that by long-term usage of levopoda the usual dosage becomes less phenomenon:
effective. Associated with an abrupt loss of mobility. 1 Schaafsma JD, Balash Y, Gurevich T, Bartels AL, 4 Giladi N, Shabtai H, Rozenberg E, Shabtai E. Gait Hausdorff JM, Giladi N. Characterization of free- festination in Parkinson's disease. Parkinsonism zing of gait subtypes and the response of each Relat Disord. 2001;7;2:135-8.
to levodopa in Parkinson's disease. Eur J Neurol 5 Nederlandse WHO-FIC Collaborating Centre.
ICF, Nederlandse vertaling van de ‘International 2 Giladi N, McMahon D, Przedborski S, Flaster Classification of Functioning, Disability and E, Guillory S, Kostic V et al. Motor blocks in Health'. http://www rivm nl/who-fic/in/ Parkinson's disease. Neurology 1992;42;2:333-9.
ICFwebuitgave pdf (28-04-02) 2002.
3 Giladi N, Treves TA, Simon ES, Shabtai H, Orlov Y, 6 Kemper HGC, Ooijendijk WTM, Stiggelbout Kandinov B et al. Freezing of gait in patients with M. Consensus over de Nederlandse Norm voor advanced Parkinson's disease. J Neural Transm Gezond Bewegen. TSG 2000;78:180-3.
KNGF Guidelines for physical therapy in patients with Parkinson's disease Current information
Courses and training
‘Halt U Valt' (Stop You Fall)
• ‘Bewegingsbehandeling bij ziekte van Parkinson' Programs are running under the name ‘Halt U Valt' in (Movement treatment in case of Parkinson's dis- different locations in the Netherlands. These courses ease), organized by the University Center (UC) seem especially suitable for people who just became ProMotion, Institute for Human Movement familiar with the diagnosis Parkinson's. These courses Sciences, Groningen University (RUG), The are easily accessible and given at innumerable loca- tions. ‘Halt U Valt' is an initiative of ‘Consument en • ‘Centraal neurologische aandoeningen' (Central Veiligheid (Consumer and Safety), TNO ‘Preventie en neurological disorders)' of the Dutch Institute Gezondheid' (Prevention and Health), GGD (Area Health of Allied Health Care (NPi), Amersfoort, The Authority) ‘Fryslân' and the GGD ‘Hart voor Brabant'. Information: Consument en Veiligheid, Amsterdam, e- • ‘Fysiotherapie in de Geriatrie' (Physical therapy in Geriatric Patients), a post-collegetraining organized by the ‘Hogeschool van Utrecht' in close coopera- ‘In Balans' (In Balance)
tion with, and under auspices of, the Dutch Society The NISB (http://www.nisb.nl ) organizes the informa- for Physical Therapy in Geriatric Patients (NVFG). tion and movement program ‘In Balance', which pays attention, among others, to safety at home, usage of General movement groups for elderly
medication, and to special movement exercises based • ‘Meer Bewegen voor Ouderen' (Moving More for Elderly; MBVO) / ‘Sport Stimulering Senioren (Sport Stimulation Seniors; SSS).
‘Kennisnetwerk Valpreventie' (Knowledge web of Fall
• ‘GALM-SCALA-projects': national sports stimulating projects for seniors at the age of 55 to 65 with a dis- The initiators of this program are the VU Medical order (SCALA ‘Sports stimulation strategy for people Centre, ‘ZonMw' and ‘Consument en Veiligheid with a Chronic Disorder: Active All Your Life') and (Consumer and safety)'. Also involved are repre- without a disorder (GALM ‘Groningen Active Life sentatives of local GGD's (Area Health Authorities), Model'). For informationon the GALM-region con- GGD Nederland and TNO ‘Preventie en Gezondheid' sultants see the NOC/NSF website http://www.sport.
(Prevention and Health). nl and UC ProMotion in Groningen (in coopera- The website of ‘Kennisnetwerk' contains, among others, tion with the Netherlands Institute for Sports and a description of relevant projects, literature and infor- Physical Activity (NISB)). mation on newly published material. From 2004 on the • Wherever a sufficient number of members of the website is only accessible for students of the program. Parkinson's Patient Society want to ‘be active' together, this society looks for opportunities to organize this (http://www.parkinson-vereniging.nl). NOC/NSF publication ‘Parkinson's disease, mov- • Nursing home Maartenshof, Groningen, The ing and health' can be pointed out to patients who Netherlands : Short Stay (after referral by a neurolo- want to exercise on their own.
gist admission takes place for a limited period for • The website http://www.sportiefbewegen.nl informs physical assessment and treatment); patients with a chronic disorder about the positive • Rehabilitation Center ‘Het Roessingh', Enschede, effects of sports and moving. By showing a number The Netherlands: day care rehabilitation; of sporting and moving opportunities, the site tries • Rehabilitation Center Breda, The Netherlands: day to stimulate everybody to play a sport (more) or care rehabilitation; move (more). Also for patients with Parkinson's dis- • Nursing home Maartenshof, Groningen The ease this site gives information on sporty moving.
Netherlands: day care rehabilitation. KNGF Guidelines for physical therapy in patients with Parkinson's disease Medication in Parkinson's disease
Medication
Name of substance
Most important characteristics
Side-effects, relevant for the
physical
therapist
• anticholinergics, especially • cognitive impairments (espe- decreasing tremor cially confusion, memory • anticholinergics, especially • injection of dopamine-receptor • orthostatic hypotension agonist (a pump is also possible) • more severe dyskinesias • as a remedy in severe and during the on-periods frequent therapy-resistant • cognitive impairments off-periods (>25% of the day) • personality changes • provides a more stable plasma level of levopoda, and thus • cognitive impairments decreasing the end-of-dose • dopamine-receptor agonist, • cognitive impairments imitates the effect of dopamine (especially visual hallucinations) • increase of freezing • peripheral edema (especially in • inhibits the breaking down of • orthostatic hypotension dopamine in the brain • sleeping impairments • intensifies and prolongs the (if taken too late in the day, effect of levodopa since the substance is trans- • possibly decreases freezing formed into amphetamine) • anticholinergics, especially KNGF Guidelines for physical therapy in patients with Parkinson's disease Medication
Name of substance
Most important characteristics
Side-effects, relevant for the
physical
levodopa/benserazide • in the body levodopa is • cognitive impairments transformed to dopamine (especially visual • strongest means to fight the • effect on rest tremor is (especially if used for more than 2-5 years) • often poor effect on the disturbed postural reflexes • dopamine-receptor agonist • see Dopergin® • dopamine-receptor agonist • see Dopergin® • dopamine-receptor agonist • see Dopergin® • dopamine-receptor agonist • see Dopergin® levodopa/carbidopa • in the body levodopa is • cognitive impairments transformed to dopamine (especially visual • strongest means to fight the • effect on rest tremor is (especially if used for more than 2-5 years) • often poor effect on the disturbed postural reflexes • improves hypokinesia and • decreases dyskinesias rigidity, but is only weakly • cognitive impairments (among others confusion) KNGF Guidelines for physical therapy in patients with Parkinson's disease Appendix 4.1
Patient Specific Complaints Questionnaire
The Patient Specific Complaints questionnaire is filled in by the patient.
Activities and movements in which the consequences of Parkinson's disease might trouble you.
Your complaints influence your daily activities and movements which are difficult to avoid. The consequences of Parkinson's disease are different for everyone. Each person wants to improve certain activities through treat- Below, there are a number of certain activities and movements that are difficult for you to perform because of your Parkinson's disease-related problems. Try to recognize the problems, caused by Parkinson's disease, that you were troubled by during the past week. Colour or mark the dot for this activity. We ask you to mark those problems which YOU FIND VERY IMPORTANT and which YOU WOULD LIKE TO CHANGE MOST in the NEXT MONTHS. The five most important activities are: • getting out of bed • getting out of a chair • sit down on a chair • sit for a long time • get in or out a car • ride in a car or bus • stand for a long time • light work in and around the house • heavy work in and around the house • walk inside the house • carry an object • pick up something from the ground • pay a visit to family, friends or acquaintances KNGF Guidelines for physical therapy in patients with Parkinson's disease Example of how to fill in: problem walking
If you place the line on the left, it means that, for you, walking is not much of an effort.
If you place the line on the right, it means that for you walking is a great effort.
Date of filling in: ……….……
How difficult was it to perform this activity during the past week? How difficult was it to perform this activity during the past week? How difficult was it to perform this activity during the past week? How difficult was it to perform this activity during the past week? How difficult was it to perform this activity during the past week? N.B. If desired, a total score can be determined by adding up the scores of the three most difficult
KNGF Guidelines for physical therapy in patients with Parkinson's disease Appendix 4.2
History of Falling Questionnaire
The History of Falling Questionnaire will be administered by the physical therapist to determine if the
patient has ever fallen (or experienced near misses), and if so, how often and under which circumstances.
Falling in general: Have you fallen or stumbled in the past 12 months for any reason, even if it had nothing to do with your Parkinson's disease? How many times have you fallen in the past 12 months (daily/weekly/monthly, etc.) Are you afraid of falling? If fallen, ask to clarify for each fall (or the pattern): Where were you when you fell? What were you doing or trying to do at the time? What do you think caused the fall? Did you loose consciousness prior to the fall? Can a pattern be identified in the falling? Near falls in general: Have you had any near falls in the past year? How often did you have near falls in the past year? In case of near falls, ask to clarify the pattern: What sort of things are you usually doing when you nearly fall? Why do you think you nearly fall? How do you save yourself from near falls? If the patient has fear of falling (FES) or if he has fallen more than once in the past year:
increased risk of falling!
KNGF Guidelines for physical therapy in patients with Parkinson's disease Appendix 4.3
Falls diary
The falls diary has to be filled in after each fall incident by the patient and his partner or caregiver.
You have fallen. We would like to know more about the circumstances prior to, during, and after you fell. Would you be so kind to answer all the questions below. Every time, choose the answer that is most appropri- ate for your situation. Prior to the fall
Where were you when you fell? Were you in a familiar or unfamiliar environment?  familiar environment  unfamiliar environment What was the surface (e.g. carpet, polished tiled floor, grass)? Were there any obstacles? (e.g. chairs, cars, doorway) What kind of footwear were you wearing? (e.g. slippers, boots, nothing) Did you have the feeling of freezing just before you fell? Were you dizzy just before you fell? Did you loose consciousness before you fell? Were you troubled by palpitations? KNGF Guidelines for physical therapy in patients with Parkinson's disease Were you troubled by dyskinesias? on or off (was the medication effective or not)?  on, the medication was effective  off, the medication was not effective Did you feel sleepy? Did those who were with you prior to the fall, think you were confused, or did you feel confused?  yes, namely: .
Were there any recent changes in your medication? How long before the fall did you take your medication for the last time? .
During the fall
At what time did you fall? .
Did you have something in your hands when you fell? What were you doing when you fell? (e.g. getting out of a chair, turning during walking) Were you distracted by something or someone when you fell? (e.g. did you talk to someone) Were you just changing your body posture when you fell?  yes, namely: .
KNGF Guidelines for physical therapy in patients with Parkinson's disease After the fall
Did you need help to get up again after you fell? Were you troubled by amnesia after the fall? Did the fall cause physical injury?  yes, namely: .
Did you have to be taken to the hospital after the fall?  yes, because: .
Do you have fear of falling or moving? KNGF Guidelines for physical therapy in patients with Parkinson's disease Appendix 4.4
(Modified) Falls Efficacy Scale (FES)
The (Modified) Falls Efficacy Scale (FES) is filled in by the patient.
Not ➤ ➤ ➤ ➤ ➤ ➤ ➤ ➤ Very How worried are you that you might fall when:
0
1
2
3
cleaning the house, such as sweeping and dusting? getting dressed and undressed? preparing a simple meal? taking a bath or shower? getting in and out of a chair? getting up or down the stairs? walking nearby the house? reaching for something in a deep, low closet? getting to the telephone before it stops to ring? 0 = not worried
1 = a little worried
2 = fairly worried
3 = very worried
Appendix 4.5
The retropulsion test is performed by the physical therapist.
During the test the physical therapist is standing behind the patient.
The retropulsion test is performed as follows: • The physical therapist gives a sudden, firm and quick backwards pull to the shoulder of the patient. • The test is performed several times, the first time without notification of what is going to happen. • The test is performed again several times with notification of what is going to happen. In doing so, the ability of the patient to adjust to an unexpected disturbance is tested. • A normal reaction is the one in which the patient takes two big and quick steps back, and the physical therapist does not have to catch the patient because the patient nearly falls. KNGF Guidelines for physical therapy in patients with Parkinson's disease Appendix 4.6
Freezing of Gait (FOG) questionnaire
The Freezing of Gait (FOG) questionnaire is filled in by the physical therapist.
Range of scores from 0 (normal / none / never) to 4 (impossible / always / maximum time) During your worst state – do you walk:  almost normally … somewhat slow  slow but fully independent  need assistance or walking aid Are your gait difficulties affecting your daily activities and independence? Do you feel that your feet get glued to the floor while walking, making a turn or when trying to initiate walking (freezing)?  very rarely: about once a month  rarely: about once a week  often: about once a day  always: whenever walking How long is your longest freezing episode?  never happened  3 to 10 seconds  11 to 30 seconds  unable to walk for more than 30 seconds How long is your typical start hesitation episode (freezing when initiating the first step)?  takes longer than 1 second to start walking  takes longer than 3 seconds to start walking  takes longer than 10 seconds to start walking  takes longer than 30 seconds to start walking How long is your typical turning hesitation: (freezing when turning)  resume turning in 1 to 2 seconds  resume turning in 3 to 10 seconds  resume turning in 11 to 30 seconds  unable to resume turning for more than 30 seconds KNGF Guidelines for physical therapy in patients with Parkinson's disease Appendix 4.7
LASA Physical Activity Questionnaire (LAPAQ)
The LASA Physical Activity Questionnaire (LAPAQ) is filled in together with the patient
The respondent is confined to bed (end of questionnaire) The respondent is confined to an electric wheelchair (end of questionnaire) The respondent is confined to a mechanical (normal) wheelchair (go to question 2) None of the above (1 to 3) is applicable (go to question 6) Now, I am going to ask you questions about your physical mobility pattern.
Do you move outside in a wheelchair?  no (end of questionnaire) Did you move outside in your wheelchair the past 2 weeks? How many times did you move outside in your wheelchair the past 2 weeks? . times (0 to 50) How long did you, each time, usually move outside in your wheelchair? . hours (0 to 10); 11 = do not know; 12 = refused . minutes (0 to 59); 60 = do not know; 61 = refused Do you walk outside? With walking outside we mean walking to go shopping or doing other daily activi- ties, like visiting someone. We do not mean: a walking tour.
 no (go to question 10) Did you walk outside during the past two weeks? With walking we mean walking to go shopping or doing other daily activities, like visiting someone. We do not mean: a walking tour.
 no (go to question 10) How many times did you walk during the past two weeks? . times (0 to 50) KNGF Guidelines for physical therapy in patients with Parkinson's disease How long did you usually walk each time? . hours (0 to 10); 11 = do not know; 12 = refused . minutes (0 to 59); 60 = do not know; 61 = refused Do you cycle? With cycling we mean cycling to go shopping or doing other daily activities, like visiting someone. With cycling we do not mean: a cycling tour.  no (go to question 14) Did you cycle during the past two weeks?  no (go to question 14) How many times did you cycle during the past two weeks? . times (0 to 50) How long did you usually cycle each time? . hours (0 to 10); 11 = do not know; 12 = refused . minutes (0 to 59); 60 = do not know; 61 = refused Do you have a garden (including allotment)?  no (go to question 20) During how many months per year do you work regularly in your garden? For example raking, planting, trimming, etc. By regularly we mean at least once a week.
. months (0 to 12) Did you work in the garden during the past two weeks?  no (go to question 20) How many times did you work in the garden during the past two weeks? . times (0 to 50) How long did you usually work in the garden each time? . hours (0 to 10); 11 = do not know; 12 = refused . minutes (0 to 59); 60 = do not know; 61 = refused KNGF Guidelines for physical therapy in patients with Parkinson's disease Did you dig in the earth during the past two weeks? Do you do sports (no mind games)?  no (go to question 31) Which sport did you do most time during the past two weeks? You can choose one of the sports on the list.  distance walking  distance cycling  gymnastics (for elderly)  cycling on a home-trainer  (country) dancing  tennis / badminton  jogging / running / fast walking  playing billiards  soccer / korfball / basketball / field hockey  volleyball / baseball Can you describe this other sport? How many times did you do this sport during the past two weeks? . times (0 to 50; if 0 go to question 25) How long did you usually do this sport each time? . hours (0 to 10); 11 = do not know; 12 = refused . minutes (0 to 59); 60 = do not know; 61 = refused Do you do another sport (no mind games)?  no (go to question 30) KNGF Guidelines for physical therapy in patients with Parkinson's disease Offer a list. Mark the sport on which the second most time is spent. Which other sports did you do during the past two weeks?  distance walking  distance cycling  gymnastics (for elderly)  cycling on a home-trainer  (country) dancing  tennis / badminton  jogging / running / fast walking  playing billiards  soccer / korfball / basketball / hockey  volleyball / baseball Can you describe this other sport? How many times did you do this sport during the past two weeks? . times (0 to 50; if 0 go to question 30) How long did you usually do this sport each time? . hours (0 to 10); 11 = do not know; 12 = refused . minutes (0 to 59); 60 = do not know; 61 = refused How many times did you perspire while sporting during the past two weeks? . times (0 to 50); 51= do not know Do you do light household tasks? With light household tasks we mean: washing the dishes, dusting, making the bed, doing the laundry, hanging out the laundry, ironing, tidying up, cooking meals.
 no (go to question 34) How many days did you usually do light household tasks during the past two weeks? . days (0 to 14); 15 = do not know; 16 = refused KNGF Guidelines for physical therapy in patients with Parkinson's disease For how much time a day did you usually do light household tasks? We try to get an average estimate of the time that is spent on the total of these tasks. It is possible that someone irons one day and does the laundry the other day, while other activities, such as tidying up, In the estimation of the time spent on light household tasks it is not really important which activity the respondent performs, since all activities require just an equal amount of energy. Remind the respondent of the fact that the time that is spent on resting in between has to be excluded.
. hours (0 to 10); 11 = do not know; 12 = refused . minutes (0 to 59); 60 = do not know; 61 = refused Do you do heavy household tasks? With heavy household tasks we mean: window cleaning, changing the bed, beating the mat, beating covers, vacuuming, washing or scrubbing the floor, and chores with sawing, carpeting, repairing or painting.
 no (go to question 37) How many days did you do heavy household tasks during the past two weeks? . days (0 to 14); 15 = do not know; 16 = refused for how much time a day did you usually do heavy household tasks? . hours (0 to 10); 11 = do not know; 12 = refused . minutes (0 to 59); 60 = do not know; 61 = refused You just told me about your physical activities in general and about your physical activities of the past two weeks. Were the past two weeks normal as compared to the rest of the past year?  yes (end of questionnaire) In what way where the past two weeks different?  disease (physical)  family occasion  else, namely: …………………………………………… (describe the other reasons) KNGF Guidelines for physical therapy in patients with Parkinson's disease Appendix 4.8
Six-minute walk test
Performing the test
With the Six-minute walk test the distance that a The instruction goes as follows: ‘The goal of this test patient can cover in six minutes is measured: is to determine how far you can walk in six minutes. • If the test is performed in a marked out, square When I say "start", walk the agreed track as fast as track (e.g. by using cones), do not walk beside the possible (if necessary point out the cones), until I say you can stop. If you want to slow down or stop, it is • If the test is performed on a treadmill, the inclina- no problem. It is also no problem if you want to go tion grade has to be zero, and on the indication of faster. Try to walk at such a pace that after six min- the patient the speed can be increased (this is not utes you have the feeling that you could not have done by the patient himself).
gone any further (that the maximum is reached).' It is important that the patient wears the same foot- wear during every measurement, and that the patient is encouraged to the same extent. KNGF Guidelines for physical therapy in patients with Parkinson's disease Appendix 4.9
Ten-meter walk test
The Ten-meter walk test is a reliable instrument to meters after the second line. Thus, the pace is not calculate the comfortable walking pace of patients influenced by starting and stopping (too early). Time with Parkinson's disease who are able to walk inde- is recorded from the moment that the patient crosses pendently. Furthermore the number of steps neces- the first line with one foot to the moment that the sary to walk ten meters at comfortable pace is used patient crosses the second line with one foot. to determine the stride length (for the use of cues). In performing the test a walking aid might be used, if The test is repeated three times, after which the aver- age pace (distance / number of seconds) and the aver- In this test the patient covers a distance between age number of steps of the three walking tests will be two lines, which are 10 meters apart. The patient is instructed to walk at a comfortable pace. He begins It is important that the patient wears the same foot- this test 5 meters before the first line and stops 5 wear during every measurement. KNGF Guidelines for physical therapy in patients with Parkinson's disease Appendix 4.10
Modified Parkinson's Activity Scale (PAS)
The Modified Parkinson's Activity Scale (PAS) is filled in by the physical therapist.
I Chair transfers
Starting position:
The patient is seated in a chair (height 40 cm), with his hands in his lap.
I will ask you later to rise from the chair. You may lean with your hands on the arm of the chair or your knees. When standing, you will have to wait a second. 1-A Rise and sit down without using hands
Will you rise without using your arms on the knees or chair? • normal, without apparent difficulties • mild difficulties (toes dorsiflex to maintain balance, arms swing forward to keep balance or use of ‘consciously performed rocks' (compensations) with the trunk) • difficult, several attempts needed or hesitations, very slow and almost no flexion of the trunk • impossible, dependent on physical assistance (perform I-B) Will you sit down again without using your arms? • normal, without apparent difficulties • mild difficulties (uncontrolled landing) • clear abrupt landing or ending up in an uncomfortable position • impossible, dependent on physical assistance (perform I-B) 1-B Rise and sit down with using hands (only if rising without using hands is impossible)
Will you try to rise again? When standing, you will have to wait a second again. You may use your hands now. • normal, without apparent difficulties • difficult, several attempts needed or hesitations, very slow and almost no flexion of the trunk • impossible, dependent on physical assistance Will you sit down again? You may use your hands again. • normal, without apparent difficulties • abrupt landing or ending up in an uncomfortable position • dependent on physical assistance KNGF Guidelines for physical therapy in patients with Parkinson's disease II Gait akinesia
Starting position: The patient sits in a chair (height 40 cm), with his hands in his lap. The middle of the
U-shape (taped on the floor) is situated three meters in front of the chair. The lengths of the sides of the U are 1 meter. First, the preferred side with regard to turning is deter- mined by asking the patient to walk and turn. Then the test is performed; during this test the turn will be to the side that is not preferred. The patient has to be able to walk without the help of others. Do you see the tape in U-shape? I will ask you later to rise. You may, if you want, use your hands. Then you walk to the U and turn to the left/right inside the U. It is up to you how you do this. Then you go back to your chair and sit down. It is not about doing it as fast as you can. It is about doing it safely. Is that clear? II-A Without an extra task
Will you rise, walk to the U and come back? Start akinesia (possibly assist with rising, which is not scored)
• normal, without apparent difficulties • hesitation or short festination • unwanted arrest of movement with or without festination lasting 5 seconds or less • unwanted arrest of movement with or without festination lasting more than 5 seconds • dependent on physical assistance to start walking • normal, without apparent difficulties • hesitation or short festination • unwanted arrest of movement with or without festination lasting 5 seconds or less • unwanted arrest of movement with or without festination lasting more than 5 seconds • dependent on physical assistance to start walking II-B Now a bit more difficult: while carrying a plastic cup which is half full of water.
Start akinesia (possibly assist with rising, which is not scored)
• normal, without apparent difficulties • hesitation or short festination • unwanted arrest of movement with or without festination lasting 5 seconds or less • unwanted arrest of movement with or without festination lasting more than 5 seconds • dependent on physical assistance to start walking • normal, without apparent difficulties • hesitation or short festination • unwanted arrest of movement with or without festination lasting 5 seconds or less • unwanted arrest of movement with or without festination lasting more than 5 seconds • dependent on physical assistance to start walking KNGF Guidelines for physical therapy in patients with Parkinson's disease II-C Now even more difficult: while counting backwards (in threes, starting with a number between 20
Start akinesia (possibly assist with rising, which is not scored)
• normal, without apparent difficulties • hesitation or short festination • unwanted arrest of movement with or without festination lasting 5 seconds or less • unwanted arrest of movement with or without festination lasting more than 5 seconds • dependent on physical assistance to start walking • normal, without apparent difficulties • hesitation or short festination • unwanted arrest of movement with or without festination lasting 5 seconds or less • unwanted arrest of movement with or without festination lasting more than 5 seconds • dependent on physical assistance to start walking III Bed mobility
Starting position: The patient is standing in front of the bed on the preferred side.
If you are standing in front of your bed at home, at which side is your pillow? III-A Without cover
Will you lie down on your back on the cover, just like you would do at home? Be sure that you are comfortable when you lie down. • normal, without apparent difficulties - difficulty with lifting legs - difficulty with moving trunk - difficulty with reaching adequate end position (functionally limiting or uncomfortable: with head uncomfortably against the head of the bed or with legs which are not relaxed (with too much flexion) • dependent on physical assistance (patient asks clearly for help or does not reach an acceptable end position) If the patient lies uncomfortably: ask him to lie straight, before rolling over to the side in bed! Will you roll over onto your side? To the left. Be sure that you lie down comfortably on your side.
• normal, without apparent difficulties - difficulty with turning trunk/pelvis - difficulty with moving trunk/pelvis - difficulty with reaching adequate end position (functionally limiting or uncomfortable: underlying shoulder and arm insufficiently in protraction and free, the head uncomfortably against the head of the bed, or less than 10 cm between trunk and the edge of the bed) • dependent on physical assistance (patient asks clearly for help or does not reach an acceptable end position) KNGF Guidelines for physical therapy in patients with Parkinson's disease Will you roll over onto your side? To the right. Be sure that you lie down comfortably on your side.
• normal, without apparent difficulties - difficulty with turning trunk/pelvis - difficulty with moving trunk/pelvis - difficulty with reaching adequate end position (functionally limiting or uncomfortable: underlying shoulder and arm insufficiently in protraction and free, the head uncomfortably against the head of the bed, or less than 10 cm between trunk and the edge of the bed) • dependent on physical assistance (patient asks clearly for help or does not reach an acceptable end position) Will you rise and sit on the edge of the bed with both feet on the ground? • normal, without apparent difficulties - difficulty with turning trunk/pelvis - difficulty with moving legs - difficulty with reaching adequate end position (no symmetric and comfortable sitting posture on the bed) • dependent on physical assistance (patient asks clearly for help or does not reach an acceptable end position) III-B With cover
Will you lie down on your back under the covers? Be sure that you lie down comfortably under the covers • normal, without apparent difficulties - difficulty with moving trunk or leg - difficulty with adjusting cover (three or more adjustments or reaching no adequate covering, for example part of the back uncovered) - difficulty with reaching adequate end position (functionally limiting or uncomfortable: with head uncomfortably against the head of the bed or with legs which are not relaxed, with too much flexion) • dependent on physical assistance (patient asks clearly for help or does not reach an acceptable end position) If the patient lies uncomfortably: ask him to lie straight! KNGF Guidelines for physical therapy in patients with Parkinson's disease Will you roll over onto your side? To the left. Be sure that you lie down comfortably under the covers.
• normal, without apparent difficulties - difficulty with turning trunk/pelvis - difficulty with adjusting cover (three or more adjustments or reaching no adequate covering, for example part of the back uncovered) - difficulty with reaching adequate end position (functionally limiting or uncomfortable: underlying shoulder and arm insufficiently in protraction and free, the head uncomfortably against the head of the bed, or less than 10 cm between trunk and the edge of the bed) • dependent on physical assistance (patient asks clearly for help or does not reach an acceptable end position) Will you roll over onto your side? To the right. Be sure that you lie down comfortably under the covers.
• normal, without apparent difficulties - difficulty with turning trunk/pelvis - difficulty with adjusting cover (three or more adjustments or reaching no adequate covering, for example part of the back uncovered) - difficulty with reaching adequate end position (functionally limiting or uncomfortable: underlying shoulder and arm insufficiently in protraction and free, the head uncomfortably against the head of the bed, or less than 10 cm between trunk and the edge of the bed) • dependent on physical assistance (patient asks clearly for help or does not reach an acceptable end position) Will you rise and sit on the edge of the bed with both feet on the ground? • normal, without apparent difficulties - difficulty with moving trunk or leg - difficulty with adjusting cover (three or more adjustments) - difficulty with reaching adequate end position (no symmetric and comfortable sitting posture on the bed) • dependent on physical assistance (patient asks clearly for help or does not reach an acceptable end position) KNGF Guidelines for physical therapy in patients with Parkinson's disease Appendix 4.11
Timed Up and Go test (TUG)
The Timed Up and Go test is used to determine how quickly the following activities can be performed at a comfortable speed: • rise from a chair; • walk back to the chair and In the starting position the patient is sitting in a chair (seat height approximately 45 centimeters) with his feet resting on the floor. The arms of the patient rest on the arms of the chair. If necessary the patient may use a walking aid. The patient has to be able to walk without the help of others. The physical therapist measures the time that the patient needs to perform the test. Appendix 4.12
Global Perceived Effect
The activity I wanted to improve was: .
This activity is now: 1 worse than ever 2 much worse 3 slightly worse 4 not changed 5 slightly improved 6 much improved 7 greatly improved … compared to the situation at the beginning of the treatment.
Appendix 4.13
Borg-scale
Feeling of exertion (not shown to the patient) extremely light (rest) very light, e.g. walking calmly fairly heavy, constant tempo KNGF Guidelines for physical therapy in patients with Parkinson's disease Appendix 4.14
The diary is filled in by the patient.
Explanation of diary
The diary is meant to evaluate the performance of the exercise program. The exercise diary is an important aid in the support of your movement activities. Based on your diary the physical therapist is able to determine your progression and to prevent overload. Furthermore, the diary will make clear if the exercise load has to be adjusted. Finally, the diary provides clear information on the way you are coping with your complaints and if you have developed an active lifestyle. A number of items in the diary you have to fill in are explained as follows: Point out how your night's rest was (good/sufficient/ moderate/bad).
Describe the exercises you performed on that day.
Number of exercise periods Report the total number of periods that you exercised today. Only the exercise periods performed as part of the exercise program you received from your physical therapist should be reported, not exercise as part of activities of daily life. (Mean) duration of the exercise periods Report the mean duration of the exercise periods that Number of resting periods How often did you have to rest during the exercises? Cause of resting periods What was the cause that made you needed to rest? (Mean) duration of the resting periods What was the mean duration of the resting periods? Total exercise duration How long did you exercise today in total? N.B. The items above are about what you really have done, not what you planned to do.
The Borg-score is an aid to estimate the subjective load, the level of exertion, on a scale of 6 to 20. Indicate how heavy the load is during exercising. This can only be done if you are familiar with using the Borg-scale.
Special circumstances If there were special circumstances, you can describe them here, such as: Injuries, complaints, or abnormal weather conditions.
Feeling afterwards How did you feel when the exercise period was over; did you have complaints for a long time after the exercise, and how severe were these complaints? Here you can describe everything you find important, and that is not yet written down.
KNGF Guidelines for physical therapy in patients with Parkinson's disease DIARY OF:
Wednesd.
Thursday
Saturday
3. Number of exercise 4. Duration per exercise 5. Number of resting 6. Cause of need to rest 7. Duration of resting 8. Total exercise duration 9. Borg-score (6-20) 11. Feeling afterwards KNGF Guidelines for physical therapy in patients with Parkinson's disease Appendix 4.15
Advice concerning
practice
To carry out the diagnostic and therapeutic process as described in the KNGF-guidelines it is advisable to have in the practice room: - an environment resembling the patient's home environment to enable the performance of a range of possible activities; - an exercise room or treadmill to perform the Six- minute walk test and to train physical condition - a mirror for visual feedback when correcting body - a metronome or a similar instrument to give audi- - an exercise room if therapy in a group is desired.
KNGF Guidelines for physical therapy in patients with Parkinson's disease Cognitive movement strategies
Sitting down
• approach the chair with firm steps, at good pace; • make a wide turn in front of the chair and stop straight in front of the chair: you must have the feeling that you walk around something (first, practice this, for example, with a cone in front of the chair, later without the cone); if necessary, turn at the rhythm of the cue you already used when you were approaching the • place your calf or back of the knee against the seat; • bend slightly forward and bend through the knees, keep your weight well above your feet; • move with your hands towards the arms of the chair or the seat, seek for support with your arms; • lower yourself in a controlled manner; sit down well, at the back of the chair.
Rise from a chair
• place your hands on the arms or the side of the seat; • move your feet towards the chair (just in front of the chair legs, two fists apart); • shift your hips to the edge of the chair; • bend your trunk (not too far, nose above the knees); • rise gently, from your legs, let your hands lean on the arms of the chair, the seat or your thighs, and then extend your trunk completely (if necessary, make use of a visual cue). In case of starting problems rock back and forth a few times and rise at the third count. Stand up after a fall
Rest after the fall • turn from lying, through side-sit (pushing up the trunk with hetero-lateral arm and homo-lateral elbow support), to the position on hands and knees; • crawl to an object to pull yourself up (for example chair, bed); • bend the strongest leg and place the opposite arm on the object (rifleman's position); • push yourself up with legs and arms.
Getting in bed
It is advisable to slide the covers to the foot of the bed first (like an accordion); the top of the cover points in the direction of the head of the bed, so it can be pulled easily over the patient. For aids and other provisions (for instance, a bed adjustable in height) the working group refers to an occupa- tional therapist.
Strategy 1
• approach the bed with firm steps, possibly with the use of a rhythmical cue , and make a wide turn in front of the bed (not over one leg), and walk at a good pace until you feel the bedside with your calf or back of • sit down on the edge of the bed (be sure there is enough distance to the pillow); • lower the upper part of the body in the direction of the pillow, and place the weight on the elbow; • lift the legs one by one into the bed so that you are lying on your side; • grab the covers with your free arm; • lower the upper part of the body onto the mattress and try to lie comfortably by moving your backside; • pull the covers over the body.
KNGF Guidelines for physical therapy in patients with Parkinson's disease • approach the bed forwards with firm steps, if necessary make use of a rhythmical cue; • bend forward, lean with your hands on the mattress and crawl onto it in such a way that you are positioned on your knees, lengthwise, at the middle of the mattress; • lie down on your side (be sure there is enough distance to your pillow); • grab the covers with your free arm and pull them over your body. Strategy 3
• approach the bed forwards with firm steps, if necessary make use of a rhythmical cue, make a wide turn in front of the bed (not over one leg), and walk at good pace until you feel the bedside with your calf or back of • sit down on the bed, with sufficient distance and in diagonal direction to the pillow, with the arms as back- • place your legs, one by one, on the mattress, turn until you are lengthwise on the mattress; • grab the covers at the end of the bed, slide your feet under the covers; • lower yourself quietly until you are lying on your back, hold on to the covers and pull them over your body. Turning in bed, from a position on the back
Smooth sheets (satin) or satin pyjamas make sliding or turning easier. Socks can give more grip on the sheets and, with that, make turning easier. Strategy 1 (through head/shoulders)
• move the cover to the side opposite to the one you want to turn to; • lift the cover with your arms and pull up your knees while you are lying on your back, put your feet flat on • move your body to the side, alternating with your feet, your pelvis, and your head and shoulders, in the opposite direction of the turn; • place your arm which is on the side you want to turn to next to your head, then turn your head and shoul- ders, use your free arm for the direction; • then lower your knees in the direction of the turn, if possible make some room under the covers with your Strategy 2 (through legs/pelvis)
• move the cover to the side opposite to the one you want to turn to; • lift the cover with your arms and pull up your knees while you are lying on your back, put your feet flat on • move yourself to the edge of the bed (alternating with your feet, pelvis, head and shoulders), in the opposite direction of the turn; • place your arm which is on the side you want to turn to next to your head; • pull up your knees as far as you can (in the direction of your chest, your feet on the mattress) and ‘drop' in the direction of the turn (if necessary lift the cover with your free arm), roll over with your pelvis; • head and shoulders follow the free arm; Strategy 3 (through arm swing)
• lift the cover and pull up your knees, while you are lying on your back, and put your feet flat on the bed; KNGF Guidelines for physical therapy in patients with Parkinson's disease • move yourself to the edge of the bed (alternating with your feet, pelvis, head and shoulders), in the opposite direction of the turn; • outstretch one or two arms vertically; • bend your knees or keep your legs straight, whatever you prefer; • make a rolling movement with your total body, using an arm swing; N.B. For all three strategies it is important that the patient does not roll off the bed and lies in the middle of the Getting out of bed: from lying on the back to sitting on the edge of the bed
The following tips might make it easier to get out of bed: • at night a nightlight is on to make visual feedback possible.
• on the bed are no light covers or smooth sheets.
• the patient wears smooth (satin) pyjamas and socks for more grip.
• the bed is not too low.
• handy aids are: elevator to lift a patient, sliding board, handles on the sides of the bed (occupational thera- • move your body a bit from the middle to the edge of the bed.
• roll over on your side (see turning in bed); • pull your knees further to your chest; • place your top arm next to your bottom shoulder; • bring your feet over the edge of the bed and, at the same time push yourself up with both arms (if help- ful, support sitting up with your bottom arm straight and the hand of your other arm placed nearby your • bend your knees, put your feet flat on the bed; • move yourself to the edge of the bed (alternating with your pelvis, shoulders and feet), in the opposite direc- tion of the turn; • shift your feet over the edge of the bed and, at the same time roll over to your side; • place the hand your top arm on the bed near the elbow of your other arm; • bring your feet over the edge of the bed and, at the same time push yourself up with both arms (if helpful, support coming to sit with your bottom arm straight and the hand of your other arm placed nearby your From sitting on the edge of the bed to standing
• sit upright on your buttocks; • lean on your arms, place your fists a bit behind your body; • shift your buttocks to the edge of the bed; • lean with your arms on the edge of the bed; • place your feet right in front of the bed, approximately 20 cm apart; • bend forward (with your nose above your knees); • stand up from your legs, if necessary rock first.
for physical therapy in patients withParkinson's disease Stadsring 159b, Amersfoort KNGF Guideline number
Postal address
P.O. Box 2483800 AE Amersfoort the Netherlands, Europe June 2004, English version: October 2006 E-mail hoofdkantoor@kngf.nlInternet www.kngf.nl KNGF Guideline Parkinson's disease Diagnostic process
Quick reference card 1: History-taking

Patient's demand and
motivation

Nature and course
onset of complaints; time since the diagnosis; severity and nature of the course; result of earlier diagnostics of the disease
problems with relationships; profession and work; social life (among others, recreational time) Impairments in
sit down; rise from floor or chair; get in or out bed; roll over in bed (sleeping problems); get in or out a car; get on or off a bike functions and
limitations in activities
body posture
possibility of an active correction of posture; pain due to postural problems; problems with reaching, grasping, and moving objects feeling of impaired balance while standing and during activities; orthostatic hypotension; difficulty with dual tasking (motor activity, cognitive) household activities (small repairs, clean, cook, slice food, hold a glass or cup without spilling); personal care (bath, get dressed/ undressed, button up, lace up shoes) use of aids; walk in the house; climb the stairs, walk short distances outside (100 m); walk long distances outside (> 1 km); start; stop; turn; speed; onset of festination; onset of freezing (use the Freezing of Gait Questionnaire); relation to falls and the use of cues influence of tiredness, the time of the day and medication on the performance of activities; influence of tremor on the performance of activities Physical activity
frequency and duration per week compared to the Dutch Standard of Healthy Moving (at least 30 min/day for 5 days a week); when having doubts: use LASA physical activity questionnaire (LAPAQ) Risk to fall
fall incidents and near fall incidents (use the questionnaire History of Falling); fear to fall; if patients had near misses the past year: use the Falls Efficacy Pressure sores; osteoporosis and mobility-limiting disorders such as arthrosis, rheumatoid arthritis, heart failure and COPD Treatment
current treatment (among others, medication and outcome) and earlier (allied) medical treatment type and outcome)
Other factors

ability to concentrate; memory; depression; feeling isolated and lonely; being tearful; anger; concern for the future insight into the disease; socio-cultural background; attitude (among others, with regard to work); coping (among others, the perception of the limitations and possibilities, the patient's solutions with regard to the limitations) Attitudes, support and relations (of, among others, partner, primary care physician, employer); accommodation (among others, interior, kind of home); work (content, circumstances, conditions, and relations) expectations of the patient with regard to prognosis; goal and course of the treatment; treatment outcome; need for information, advice and coaching Quick reference card 2: Physical examination
reaching and
grasping
Physical
Expressing itself in reduced:
Expressing itself in:
Expressing itself in:
❑ sitting down (chair) ❑ generalized flexion ❑ standing (eyes open / ❑ problems with starting Mobility of joints
❑ rising from a chair ❑ problems with stopping ❑ thoracic spinal column ❑ rising from the ❑ generalized flexion ❑ rising from a chair ❑ shortened stride length ❑ cervical spinal column ❑ turning while standing ❑ increased stride width ❑ other joints, namely: ❑ getting in and out ❑ generalized flexion ❑ decreased stride width ❑ bending forward ❑ decreased speed ❑ rolling over in bed ❑ generalized flexion ❑ dual tasking: 2 × motor ❑ decreased trunk rotation Muscle length
❑ getting in or out a ❑ decreased arm swing ❑ calf muscles ❑ no possibility of ❑ dual tasking: cognitive + active correction of ❑ other muscles, namely: pain (especially in reaching and grasping Freezing can be provoked:
❑ by starting to walk Possibly expressing itself in:
❑ during walking ❑ trunk extensors ❑ knee extensors ❑ dual tasking: cognitive + ❑ plantar flexors of the ankle ❑ other muscles, namely: ❑ moving objects ❑ obstacles (e.g. chairs)❑ other, namely ❑ control of respiration ❑ physical condition Measures for
identification

❑ Patient Specific Complaints ❑ Global perceived effect ❑ Timed Up and Go test Supplementing ❑ LASA Physical Activity
No specific measuring Retropulsion test Parkinson Activity Scale measures for
instrument advised Falls Efficacy Scale Timed Up and Go test ❑ Six-minute walk test ❑ Timed Up and Go Freezing of Gait ❑ Questionnaire History of questionnaire❑ Ten-meter walk test Parkinson's disease Therapeutic process
Quick reference card 3: Specific treatment goals

Surgery (-tomy or stimulation)
start of first limitations in activities (mid phase) Physical therapeutic treatment
Early phase
Mid phase
Late phase
Hoehn and Yahr 1-2.5 Hoehn and Yahr 2-4 • as in early phase, and also: • as in mid phase, and also: • prevention of fear to move • maintain or improve activities, • maintain vital functions • prevention of fear to fall • prevention of pressure sores Quick reference card 4: Treatment strategies
Stimulation of activities
Strategy
Perform transfers (more) independently Practice transfers by using cognitive movement strategies and on/off cues for movement initiation Body posture
Conscious normalization of body posture Practice relaxed and coordinated moving; providing feedback and advice Reaching and grasping
Improve reaching and grasping, and manipulating and Practice reaching and grasping by using cues and cognitive movement strategies Improve balance during activities Practice balance, train muscle strength (see prevention of falls) Improve walking (independently); the objective is to Practice walking by using cues for initiation and continuation of walking, give increase the (comfortable) walking speed; however, safety instruction and train muscle strength and trunk mobility Prevention
Goal

Preserve or improve physical condition Provide information on the importance of moving and playing sports, training of physical capacity: muscle strength (with the emphasis on trunk and leg muscles); aerobic capacity; and joint mobility (among others thoracic kyphosis, axial rotation, and length of muscles of calf and hamstrings) Prevention of pressure sores Give advice and adjust the patient's body posture in bed or wheelchair (possibly in consultation with an occupational therapist); (supervised) active exercises toimprove cardiovascular condition and prevention of contractures Decrease or prevent falls List possible causes of falls by means of falls diary; provide information and advice; train strength, body posture, coordination and balance, attuned to the cause of problems with maintaining balance and the increased falls risk; decrease the fearto fall, (if necessary) provide hip protectors

Source: http://www.appde.eu/pdfs/Dutch%20Parkinson's%20Physiotherapy%20Guidelines.pdf

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2013 CLINICIAN'S GUIDE TO PREVENTION AND TREATMENT OF OSTEOPOROSIS Attention Clinicians: It is important to note that the recommendations developed in this Guide are intended to serve as a reference point for clinical decision-making with individual patients. They are not intended to be rigid standards, limits or rules. They can be tailored to individual cases to incorporate personal facts that are beyond the scope of this Guide. Because these are recommendations and not rigid standards, they should not be interpreted as quality standards. Nor should they be used to limit coverage for treatments. This Guide was developed by an expert committee of the National Osteoporosis Foundation (NOF) in collaboration with a multi-specialty council of medical experts in the field of bone health convened by NOF. Readers are urged to consult current prescribing information on any drug, device or procedure discussed in this publication. National Osteoporosis Foundation 1150 17th St., NW, Suite 850, Washington, DC 20036 © REVISED 2013. National Osteoporosis Foundation (NOF). All rights reserved. No part of this Guide may be reproduced in any form without advance written permission from the National Osteoporosis Foundation. BoneSource® is a registered trademark of the National Osteoporosis Foundation. Suggested citation: National Osteoporosis Foundation. Clinician's Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2013.

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